Integrating Palliative Care Social Workers Into Sub-Acute Settings: A Feasibility Trial

Of the nearly 800,000 seniors admitted to Skilled Nursing Facilities for rehabilitation (SNF
rehab) annually in the U.S., approximately 20% will be newly institutionalized, 25-50% are
readmitted back to the hospital within 30 days at a cost of $4.34 billion, and 9% will die in
the next year. Clearly this population represents an ideal target for palliative care
interventions such as decreasing symptom burden, improving quality of life, and ensuring that
the medical care provided is congruent with patient goals and preferences. Unfortunately,
health professionals working in the SNF rehab setting are rarely trained in palliative care.
While the current standard of care in the SNF rehab setting typically includes social service
assessment and case management, the care plans developed are frequently focused only on
immediate, short-term issues and are not communicated as the patient is discharged to a
different level of care. Existing literature supports the need to assist patients in
navigating care transitions through standardized systems and patient/family activation.
However, the transition from hospital to SNF and from SNF to community has received little
attention, even though these are some of the most complex patients at high risk for poor
outcomes. The broad goal of the research team is to optimize care for high-risk seniors
admitted to SNF rehab by using a social work led, therapeutic intervention designed to align
goals of care and improve communication across multiple care settings.

ALIGN (Assessing & Listening to Individual Goals and Needs), a palliative social work led
intervention, focuses on defining patient and caregiver goals and values through an
ecological assessment with standardized monitoring and reassessment, providing education
about disease trajectory, facilitating communication between the patient and the care team,
and developing a patient-centered care plan that accompanies the patient across all future
transitions. ALIGN was previously tested in a long-term acute care hospital setting as part
of a quality improvement project that demonstrated decreased hospital readmissions, increased
use of hospice, improved self-reported patient care experience, and higher levels of advance
directive completion. This pilot study will be conducted to determine the feasibility of
applying ALIGN to the SNF rehab population. The current protocol will enroll 60 patients aged
65+ at the time of admission to receive the ALIGN intervention along with at least 60
caregivers. The Investigators will also enroll 120 patients and 60 caregivers to receive care
as usual. The proposed specific aims (SA) and Hypotheses (H) are:

SA1: To determine the feasibility of conducting a trial of ALIGN in older persons and their
caregivers admitted to SNF rehab using a pragmatic, stepped-wedge design.

H1: The ALIGN intervention will be feasible if a) eligibility, enrollment, refusal, retention
and attrition rates are within 20% of expected; b) facility staff/providers and participants
(patients and caregivers) find the intervention acceptable (semi-structured qualitative
interviews)

SA2: To conduct an exploratory analysis to estimate the effect size of ALIGN vs usual care on
the primary patient-centered outcome, quality of life (FACT-G), and caregiver-centered
outcome, caregiver burden (Zarit caregiver burden scale) and the secondary outcome (health
care utilization). The investigators hypothesize that compared to control at 60-days
post-enrollment, the ALIGN subjects will have:

H2a: A clinically meaningful difference in the FACT-G (3-7 points on the overall scale) for
patients.

H2b: A clinically meaningful difference in the Zarit Caregiver burden scale (8±15) for
caregivers.

H2c: A 20% relative decrease in 60-day readmission to hospital.

In addition to the key primary and secondary outcome measures listed above, the investigators
will also explore the effect of ALIGN on utilization of palliative care/hospice, hospital
length of stay, advance directive documentation, and care experience (Advanced Illness
Coordinating Care Survey).

Inclusion Criteria:

High risk for hospital readmission based on LACE Score > 7;

- Length of stay in days,

- Caregivers must be > 18 years old,

- Comorbidity,

- ER Visits in past 6 months)

- Admitted to SNF

- Decisional capacity to consent or proxy available to consent

- English speaking

Exclusion Criteria:

- Lacking proxy available for consent