Improving Barriers to Hospice Referrals for Older Adults in the Primary Care Setting

Many primary care providers (PCP) are reluctant to refer older adult patients (>65 years old) for hospice services even though these services have shown to improve end-of-life care. This reluctance in referring is a problem because many older adults who would potentially qualify for hospice services are not being referred and, as a result, are not benefitting from hospice services, or only receiving services for a portion of the time for which they would qualify. The end result is underutilization of hospice services, which undermines delivery of high quality care to older adult patients. The PCP is key in facilitating this change. The purpose of this project was to determine barriers to hospice referral in the primary care setting (e.g. knowledge gaps, lack of resources, poor patient education, etc.) to increase appropriate/timely utilization of these service therefore improving end-of-life experience for both patient that qualify and their caregivers. The objectives of this project were to 1) assess both hospice providers' and PCPs' perceptions of what barriers exist for primary care providers in referring older adults to hospice, particularly PCP knowledge deficits surrounding hospice referral; 2) develop a learning module regarding hospice and its services that addresses the barriers identified by both hospice providers and PCPs; 3) improve PCPs' knowledge of hospice and its services; and 4) disseminate findings at student poster presentation and prepare a submission for a professional conference. Research suggests that potential barriers to making hospice referrals include knowledge deficits in regards to hospice, communication issues with patients and families, and inter-familial issues between patients and their families. In addition, it has been recommended that provider education be enhanced, with increased focus on effective communication regarding disease trajectories, goals of care, advanced directives, and end-of-life care. It is suspected that these barriers continue to go unaddressed for practicing PCPs, and continue to reinforce underutilization of hospice services. As part of the implementation and evaluation process, a questionnaire was developed to assess referral barriers, and was delivered to both PCPs (n=10) and hospice providers (n=9). Based on the survey findings, which found lack of education regarding hospice and unfamiliarity with the hospice referral process among top barriers, an educational module was developed and sent to the original PCP participants. Those completing the educational module were then asked to answer a questionnaire assessing their knowledge of hospice. After delivery of the educational module, questionnaire data showed a 25% improvement in hospice knowledge scores (p<0.05). An abstract of these findings was submitted to the 2017 Snowbird CME Conference in Utah for poster presentation. While beyond the scope of this project, the long-term goal is to increase appropriate and timely utilization of hospice referrals in all PCP settings. In summary, hospice is a vital resource that has potential for positively affecting older adults in need of its services. Determining barriers to appropriate and timely hospice referral making in the primary care setting is necessary to improving end-of-life care. Development and dissemination of educational modules based on provider-perceived barriers may help to close knowledge gaps and remove barriers to making hospice referrals for this population.

Running head: IMPROVING BARRIERS TO HOSPICE Improving Barriers to Hospice Referrals for Older Adults in the Primary Care Setting Andrew Cardon, BSN, RN, DNP Student University of Utah College of Nursing In partial fulfillment of the requirements for the Doctor of Nursing Practice degree 1 IMPROVING BARRIERS TO HOSPICE 2 Executive Summary Many primary care providers (PCP) are reluctant to refer older adult patients (>65 years old) for hospice services even though these services have shown to improve end-of-life care. This reluctance in referring is a problem because many older adults who would potentially qualify for hospice services are not being referred and, as a result, are not benefitting from hospice services, or only receiving services for a portion of the time for which they would qualify. The end result is underutilization of hospice services, which undermines delivery of high quality care to older adult patients. The PCP is key in facilitating this change. The purpose of this project was to determine barriers to hospice referral in the primary care setting (e.g. knowledge gaps, lack of resources, poor patient education, etc.) to increase appropriate/timely utilization of these service therefore improving end-of-life experience for both patient that qualify and their caregivers. The objectives of this project were to 1) assess both hospice providers' and PCPs' perceptions of what barriers exist for primary care providers in referring older adults to hospice, particularly PCP knowledge deficits surrounding hospice referral; 2) develop a learning module regarding hospice and its services that addresses the barriers identified by both hospice providers and PCPs; 3) improve PCPs' knowledge of hospice and its services; and 4) disseminate findings at student poster presentation and prepare a submission for a professional conference. Research suggests that potential barriers to making hospice referrals include knowledge deficits in regards to hospice, communication issues with patients and families, and inter-familial issues between patients and their families. In addition, it has been recommended that provider education be enhanced, with increased focus on effective communication regarding disease trajectories, goals of care, advanced directives, and end-of-life care. It is suspected that these barriers continue to go unaddressed for practicing PCPs, and continue to reinforce underutilization of hospice services. As part of the implementation and evaluation process, a questionnaire was developed to assess referral barriers, and was delivered to both PCPs (n=10) and hospice providers (n=9). Based on the survey findings, which found lack of education regarding hospice and unfamiliarity with the hospice referral process among top barriers, an educational module was developed and sent to the original PCP participants. Those completing the educational module were then asked to answer a questionnaire assessing their knowledge of hospice. After delivery of the educational module, questionnaire data showed a 25% improvement in hospice knowledge scores (p<0.05). An abstract of these findings was submitted to the 2017 Snowbird CME Conference in Utah for poster presentation. While beyond the scope of this project, the long-term goal is to increase appropriate and timely utilization of hospice referrals in all PCP settings. In summary, hospice is a vital resource that has potential for positively affecting older adults in need of its services. Determining barriers to appropriate and timely hospice referral making in the primary care setting is necessary to improving end-of-life care. Development and dissemination of educational modules based on provider-perceived barriers may help to close knowledge gaps and remove barriers to making hospice referrals for this population. The Doctor of Nursing Practice Scholarly Project committee included: Chair Advisor: Andrea Wallace, PhD, RN FNP Specialty Track Director: Julie Balk, DNP, APRN, FNP-BC, CNE Assistant Dean MS & DNP Programs: Pamela Hardin, PhD, RN, CNE Content Expert: Paige Kimball, MS, APRN, FNP-BC IMPROVING BARRIERS TO HOSPICE 3 Table of Contents Executive Summary ........................................................................................................................ 2 Table of Contents ............................................................................................................................ 3 Problem Statement .......................................................................................................................... 6 Clinical Significance ....................................................................................................................... 7 Purpose and Objectives ................................................................................................................. 10 Literature Review.......................................................................................................................... 10 Search Strategy ........................................................................................................... 10 Hospice Definition ...................................................................................................... 11 History of Hospice and Hospice Philosophy .............................................................. 11 Qualifications for Hospice .......................................................................................... 12 Current Hospice Utilization ........................................................................................ 12 National usage of all individuals.................................................................. 13 Population characteristics of those on hospice.. .......................................... 13 Benefits of Hospice ..................................................................................................... 13 Current Referral Practices ........................................................................................... 15 Theoretical Framework ................................................................................................................. 15 Implementation ............................................................................................................................. 17 Objective 1: Assess Providers' Use, Perceptions, and Knowledge of Hospice .......... 17 Objective 2: Develop Educational Module ................................................................. 18 IMPROVING BARRIERS TO HOSPICE 4 Objective 3: Improve Primary Care Providers' Knowledge of Hospice .................... 19 Objective 4: Disseminate Findings ............................................................................. 19 Evaluation ..................................................................................................................................... 19 Objective 1: Assess Providers' Use, Perceptions, and Knowledge of Hospice .......... 20 Objective 2: Develop Educational Module ................................................................. 24 Objective 3: Improve Primary Care Providers' Knowledge ....................................... 24 Objective 4: Disseminate Findings ............................................................................. 25 Results ........................................................................................................................................... 26 Limitations/Barriers .................................................................................................... 27 Recommendations ......................................................................................................................... 27 DNP Essentials.............................................................................................................................. 28 Conclusions ................................................................................................................................... 29 References ..................................................................................................................................... 31 Figures........................................................................................................................................... 33 Figure 1. ACE Star Model of Knowledge Transformation......................................... 34 Appendices .................................................................................................................................... 35 Appendix A: DNP Project Proposal PowerPoint Presentation ................................... 36 Appendix B: IRB Exemption Letter ........................................................................... 40 Appendix C: Pre-Education Questionnaire ................................................................. 41 IMPROVING BARRIERS TO HOSPICE 5 Appendix D: Participant Recruitment Letter .............................................................. 43 Appendix E: Educational Module............................................................................... 44 Appendix F: Post-Education Questionnaire................................................................ 56 Appendix G: Final Poster Presentation ....................................................................... 57 Appendix H: Pre-Education Questionnaire Section 2 Responses............................... 58 Appendix I: Pre-Education Questionnaire Section 3 Responses ................................ 59 Appendix J: Pre-Education Questionnaire Section 3 Results ..................................... 60 Appendix K: Believed Should vs Actual Consults Hospice, Palliative Care, ACP ... 61 Appendix L: Pre-Education Questionnaire Free Response ........................................ 64 Appendix M: 2017 Snowbird CME Abstract Submission.......................................... 65 Appendix N: Final Results Pre- vs Post-Education Results Comparison ................... 66 IMPROVING BARRIERS TO HOSPICE 6 Improving Barriers to Hospice Referrals for Older Adults in the Primary Care Setting Problem Statement Many primary care providers (PCP) are reluctant to refer older adult patients (>65 years old) for hospice services, even though these services have shown to improve end-of-life care (Ogle, Mavis, & Wang, 2003). Research by Ogle, Mavis, and Wang (2003) state potential barriers to such referrals include knowledge deficits in regards to hospice, communication issues with patients and families, and inter-familial issues between patients and their families. More recent research by Snyder, Hazelett, Allen, and Radwany (2013) concludes that provider education needs to be enhanced. They state that education must focus on effective communication regarding disease trajectories, goals of care, advanced directives, and endo-oflife care. Furthermore, education should focus on knowledge of and access to hospice services. This reluctance in referring is a problem because many older adults that would potentially qualify for hospice services are not being referred by their PCPs. Therefore, these patients are not benefitting from hospice services at all, or only receiving services for a portion of the time for which they would qualify. The result is underutilization of hospice services, which creates an ever-growing deficit in improving end-of-life care for older adults. Hospice, a primarily Medicare-paid treatment option, offers free medical care, pain management, emotional/spiritual support, and other services to qualifying patients and their loved ones (National Hospice and Palliative Care Organization, 2014). The number of individuals admitted into hospice care continues to increase at a slow rate, particularly among older adults. Yet there is still a majority of older adults who do not benefit because their need for hospice services is not identified. According to Kirolos et al. (2014) approximately 20-25% of people who die in the United States use hospice services. Of those 25%, half have hospice IMPROVING BARRIERS TO HOSPICE 7 admission periods that last on average 22 days or less, and another 10% are admitted within 24 hours of end-of-life. These data indicate that a large number of individuals are not being referred to hospice services in a timely manner, or in a manner that will allow them to fully benefit from the hospice program. In addition to the disparity of numbers of older adults being referred to hospice, there is disparity in referrals among racial and ethnic groups. According to the National Hospice and Palliative Care Organization (NHPCO) (2014), White/Caucasians represent the greater portion of hospice patients while Hispanics and other non-White/Latino ethnicities represent a markedly minority portion of admissions. While further investigation into causes of this disparity (i.e. insurance, culture/ethnicity, or referral disparities) will not be the main focus of this project, it remains a pertinent component to the underlying issue. Primary care providers play a vital part in the health care of the older adult population. In large part, how care is given is based on the education and guidance given to the patients and families by primary care providers. Further understanding what PCPs identify as barriers to making hospice referrals, and how they believe these barriers might be overcome, will likely increase patients' overall knowledge of hospice and potential utilization. This new knowledge may result in an increase of quality of end-of-life care for both patients and their families. Clinical Significance As mentioned previously, hospice, a Medicare-paid treatment option, offers free medical care, pain management, emotional/spiritual support, and other services to qualifying patients and their loved ones (National Hospice and Palliative Care Organization, 2014). While hospice is not solely for older adults, NHPCO (2014) reported that nearly 84% of hospice patients were 65 years old or older in 2013. The most common diagnosis of patients referred to hospice is cancer, IMPROVING BARRIERS TO HOSPICE 8 which attributed to 36.5% of admissions to hospice in 2013. Of the remaining 63.5% noncancerous diagnoses, the top four diagnoses are dementia (15.2%), heart disease (13.4%), lung disease (9.9%), and debility unspecified (5.4%). According to the National Council on Aging (n.d), 92% of older adults have a chronic condition with two-thirds of their deaths projected to being attributed to heart disease, cancer, stroke, and diabetes directly. With advances in medicine, older adults are able to live longer with these chronic diseases and accede the once typical fast deaths associated with them. These newer, yet longer stages of chronic disease come with additional associated morbidities. These associated morbidities increase the degree of debilitation on this population putting them in health states that would limit their estimated life span to less than six months. This increases the older adult's likelihood of needing hospice services and increases chances of qualification. Currently there are no concrete statistics showing the number of individuals who would qualify for hospice services but who are not enrolled. The high number of older adults with these progressive chronic diseases, the number of deaths caused by complications associated with these chronic diseases, and the disproportionate number of older adults admitted to hospice (compared to number of older adults with chronic diseases) infers a potential gap between the number of those who would qualify and actually use hospice services. Stakeholders involved with this project are primary care providers (physicians, nurse practitioners, and physician assistants), older adult patients seen in primary care, patients' families and caregivers, and hospice providers. Providers will be affected because they will be evaluated to determine knowledge level and barriers to hospice referral, and if barriers were removed, would potentially increase the number of appropriate referrals to hospice. With these referrals, care may be maintained with primary care, transferred solely to hospice care IMPROVING BARRIERS TO HOSPICE 9 practitioners, or become a collaborative effort. Patients currently in need of hospice services, who have not been educated or given the option of hospice care, will be greatly affected. This will include all future patients with potential hospice needs, as their needs will be met sooner than in current conditions. Patients' families and caregivers will be affected as the resources provided by hospice will allow for decreased financial burden, and allow for increased emotional, spiritual, and medical support. Lastly, hospice providers will be affected since a greater number of referrals will be made and ultimately more hospice patients admitted into care resulting in greater workload and potentially greater revenue. Among the potential barriers to referring patients to hospice are lack of provider knowledge about hospice, including its purpose, services, and referral process; poor preparedness of patients in topics related to death and dying, including advanced directives, and a clear understanding of time trajectory for the progression of their given illness. If these barriers continue to go unaddressed, the number of older adults needing hospice care that would qualify, but not receive care will increase. This is because current rates of referral will not be able to maintain pace with the growing number of older adults. This will lead to poorer end-of-life outcomes and a decrease in positive end-of-life experiences by both patients and their caregivers. Conversely, if current practices change, primary care providers involved in the treatment of older adults will proactively provide thorough and timely hospice education to patients who currently have need, or may need the services in the future. This will likely result in patients being more prepared to make decisions related to the use of hospice, and make informed decisions that better coincide with their end-of-life goals. Potential policy implications include requiring primary care providers to take part in continued education related to hospice care, how to approach the topic, and the procedure to IMPROVING BARRIERS TO HOSPICE 10 make referrals. Also, increased push for discussion on advanced care planning, what it is, why it is needed, and how it is utilized. While hospital settings and other specialized facilities that use Medicare and Medicaid funds are required to ask or update information on advanced directive, primary care settings have yet to be scrutinized for not visiting this topic. Making policy changes such as described above would ensure a better-founded knowledge of the subject to providers and patients and prepare clinicians with the tools to make this a positive and beneficial experience for all parties involved. Purpose and Objectives The purpose of this project is to identify current barriers in making appropriate referrals to hospice for older adults in the primary care setting in order to improve end-of-life experience in this population. The objectives of this project were to: 1. Assess both hospice providers' and primary care providers' perceptions of what barriers exist for primary care providers in referring older adults to hospice, particularly primary care provider knowledge deficits surrounding hospice referral; 2. Develop a learning module regarding hospice and its services that addresses the barriers identified by both hospice providers and primary care providers; 3. Improve primary care providers' knowledge of hospice and its services; and 4. Disseminate the collected information at student poster presentation and submit to professional conference. Literature Review Search Strategy A review of the literature was conducted by using PubMed and CINAHL. Search terms used included "provider," "primary care," "older adult," "hospice," "referral," "barrier," IMPROVING BARRIERS TO HOSPICE 11 "education," and "end of life." A brief review of selected article reference lists was also used to locate additional references. Hospice Definition Hospice, a Medicare/Medicaid paid treatment option, offers free medical care, pain management, emotional/spiritual support, and other services to qualifying patients and their loved ones (National Hospice and Palliative Care Organization, 2014). The focus of hospice is to provide caring services and not curing services to its participants with any terminal illness regardless of age, religions background, or race (National Hospice and Palliative Care Organization, 2014). In general, these services are provided in a variety of locations including the patient's home, freestanding hospice centers, hospitals, nursing homes, and a variety of other long-term care facility types depending on the individual patient and the patient's circumstances. History of Hospice and Hospice Philosophy The conceptualization of hospice began in the early twentieth century. This period was a time where the medical system began to see an increase in technological and pharmacologic advances laying the way for specialization, more inpatient care, and new interventional techniques. Although advances were occurring, there continued to be deficiencies in the health care system, especially as it pertained to dying patients, as noted by Dame Cicely Saunders a nurse/social worker turned physician. Saunders saw dying as a valuable, enriching part of a person's life and, as such, demanded respect, and attention. Based on this attitude, Saunders built the foundation on which the hospice philosophy stands, with central features including controlling pain, utilizing interdisciplinary care, and recognizing the importance of the end-oflife experience (Hutcheson, 2011). IMPROVING BARRIERS TO HOSPICE 12 Qualifications for Hospice Persons who are eligible for hospice are anyone who is terminally ill. The term terminally ill is defined as anyone with a medical prognosis that estimates the persons' life expectancy to 6 months or shorter given the illness follows a normal course (Hutcheson, 2011). Regulations set forth by Medicare states that patient eligibility for hospice care coverage can only be approved if both the attending physician of the patient and the hospice company medical director certify that the patient has a life expectancy of less than or equal to 6 months. Determination of prognosis and the certification of terminal illness is sometimes complex. The Centers for Medicare & Medicaid services formulated a document, which contains several of the most common hospice diagnoses with local coverage determinations. These determinations are checklists that have become required criteria that must be satisfied in order for hospice eligibility to be obtained. For diagnoses not included in the local coverage determinations it is up to the provider to make best judgement, supporting certification of terminal illness utilizing review of current literature (Hutcheson, 2011). Current Hospice Utilization According to estimates based on the 2010 US census, there were nearly 317,780,510 residents within the United States in 2014 (U.S. Census Bureau Population Division, 2015). IMPROVING BARRIERS TO HOSPICE 13 National usage of all individuals. In the year 2013 there was an estimated 1.5 to 1.6 million individuals that received hospice services at some point in time including dying while receiving hospice services or that received services that were then removed due to change in health status or illness prognosis (National Hospice and Palliative Care Organization, 2014). Population characteristics of those on hospice. As of 2013 the percentages of female and male patients on hospice was 54.7% for female and 45.3% for male for the total hospice population. Non-Hispanic or non-Latino ethnicity patients represented 93.2% of patients with only 6.8% being represented by the Hispanic or Latino ethnic groups. Further breakdown shows that white/Caucasians represent 80.9% of the hospice community in 2013 with American Indian and Alaskan Natives representing the least at 0.3% (National Hospice and Palliative Care Organization, 2014). While hospice is not solely for older adults, NHPCO (2014) reported that nearly 84% of hospice patients were 65 years old and older in 2013. The most common diagnosis of patients on hospice is cancer, which attributed to 36.5% of admissions to hospice in 2013. Of the remaining 63.5% non-cancerous diagnoses, the top 4 diagnoses are dementia (15.2%), heart disease (13.4%), lung disease (9.9%), and debility unspecified (5.4%). According to the National Council on Aging (NCOA) (n.d), 92% of older adults have a chronic condition with two-thirds of their deaths projected to being attributed to heart disease, cancer, stroke, and diabetes. This signifies that a majority of older adults have or will have chronic diseases that have the potential for hospice eligibility. Benefits of Hospice Hospice gives patients and families access to a wide range of services provided by an array of individuals, including volunteers. In 2013 nearly 355,000 thousand volunteers provided IMPROVING BARRIERS TO HOSPICE 14 16 million hours of service including activities such as spending time with patients and families (60.9% of service time), in addition to clinical and general support activities. This time is in addition to other providers that come to the attention of hospice patients. Beyond the time of death of a patient, bereavement support is normally offered in the form of follow-up phone calls, visits, and mailings throughout the first post-death year (NHPCO, 2014). In a recent study by Obermeyer, Makar, Abujaber, Dominici, Block, and Cutler (2014), a sampling of Medicare fee-for-service beneficiaries with poor prognosis cancer (matched groups of those on hospice and those not on hospice) showed that those receiving hospice care produce significantly lower rates of hospitalizations, admissions to intensive care units, and fewer procedures surrounding end-of-life. In addition, during the last year of life, those on hospice services have health care expenditures significantly lower than those not utilizing hospice services (Obermeyer et al., 2014). Hospice helps reduce the number of unnecessary treatments, hospitalizations, and cost for not only the patient and their caregivers, but for Medicare/Medicaid. According to Finestone and Inderwies (2008), there is a large amount of evidence that supports that higher quality of life exists in patients on hospice when compared to those that are terminally ill in the hospital, not on hospice. A high number of studies which evaluate the quality of end-of-life care outside of the hospital setting consistently show that family members are more likely to find favorable dying experiences of their dependents when hospice services are chosen than when not. This information coincides with growing evidence that hospice provides high quality care with high consumer satisfaction. In addition to patient and family satisfaction, research has also shown that in certain diagnoses, such as congestive heart failure, IMPROVING BARRIERS TO HOSPICE 15 those on hospice service live an average of 29 days longer than those with the same condition not on hospice service (Finestone & Inderwies, 2008). Current Referral Practices The process of making a hospice referral is non-complex. While a Medical Doctor is the most often person to make a referral to hospice, the referral can be made by anyone that has a connection to the care of the patient. This may include a social worker, a family member, patients themselves, or any other individual who sees that the patient has, or may have, a terminal illness and may benefit from hospice services. One call to a hospice agency is usually adequate to initiate a visit from an admissions specialist (usually nurse or social worker) who collects demographic and medical information regarding the patient, explains eligibility requirements, and services that the hospice provides. Regardless of who makes the referral, the attending provider for the patient must be consulted before admission to hospice can be made. In the case where a current attending provider does not agree with the referral the patient may choose to change their primary attending provider. Theoretical Framework For purposes of guiding this scholarly project, the ACE Star Model (Stevens, 2004) was utilized. The purpose of this framework is to address the development of evidence-based practice (EBP), the process and outcomes of EBP, and the translation of EBP into actual practice. Stevens (2004) stated that there are two chief obstacles to achieving evidence-based practice. The first hurdle is the complexity of knowledge that exists at this point in the information and technology world. New knowledge emerges constantly making it more difficult to stay current on all resources and literature newly available. Stevens (2004) states the second hurdle to implementation of EBP is the medium by which the information is presented. More often than IMPROVING BARRIERS TO HOSPICE 16 not, the information or literature is not readily available in a form that is easy for clinicians to access or easily decipher for implementation into practice. Steven (2004) proposed that in order to overcome this barrier, material should be summarized, reducing both the complexity and amount of information, and should be transformed into a medium conducive for application in clinical practice. While the ACE Star Model is based on the presentation and transformation of EBP, it can also be applied to the transformation and dissemination of basic knowledge to clinician which is how it will be utilized for this project. The development of an educational module for primary care providers, concerning hospice, will help to overcome the two barriers listed above and help to increase base knowledge of hospice. The ACE Star Model of Knowledge Transformation guided the development of an educational module based on recent literature and data collected from providers currently involved in hospice medicine and providers practicing in the primary care setting. The ACE Star Model (see Figure 1) consists of five stars points, or steps, which direct and organize EBP, or in this case knowledge, processes and approaches (Stevens, 2004). Knowledge transformation occurs in five steps according to the ACE Star Model. The first step consists of knowledge discovery through methods of research and inquiry. The second step takes the synthesized research and evidence and summarizes it into scientific statements. Together steps one and two build upon each other, as step one focuses on single studies or findings, and step two reviews multiple studies and brings the culmination of information into knowledge generation. In the third step the development of practice guidelines are started. With guidelines generated step four begins to integrate those guidelines into clinical practice. The final step in the process is observation of endpoints and outcomes to evaluate if the integration of knowledge had an effect, more particularly the desired effect. IMPROVING BARRIERS TO HOSPICE 17 This scholarly project aimed to lay a foundation for future scholarly work related to steps four and five in the process. Steps one and two were accomplished through collection of data through questionnaires completed by both hospice practitioners and primary care practitioners. Step two was more specifically accomplished through a thorough literature review and collaboration with a hospice content expert. The knowledge gained by both collection of data and literature review was used to develop an educational module for clinical practice to satisfy step three of the process. Implementation The primary target population for this project included primary care providers (PCPs, MD, DO, NP or PA), working in family practice or internal medicine settings, and a secondary target population of hospice providers of similar provider education backgrounds. Approval of this project was granted after completion of a project proposal defense presentation (see Appendix A) which panel included the department executive director, program director, project chair, and other participating faculty. Approval and exemption status was granted by the University of Utah Institutional Review Board (see Appendix B). Further, a content expert lent guidance during the project. The implementation and success of this project was produced through the support of voluntary providers in primary care and hospice care throughout the Salt Lake region. Objective 1: Assess Providers' Use, Perceptions, and Knowledge of Hospice The implementation of this project started with a formal literature review that addressed the key topics of hospice. This information was used to address objective one, to assess hospice provider and PCP perceptions of what barriers exist for PCPs in terms of referring older adults to hospice, including PCP knowledge deficits surrounding hospice. A pre-education questionnaire IMPROVING BARRIERS TO HOSPICE 18 was developed (see Appendix C), and distributed to 16 individual hospice providers and 52 individual PCPs, utilizing the online survey system RedCap®. Participants were recruited from a convenience sample of practices in the Salt Lake Valley. Information was obtained through electronic web searches. Following the IRB protocol, a research participation proposal letter (see Appendix D) was sent or distributed to office managers prior to distributing the questionnaire link. Potential participants had the option to request no further distribution of information. This questionnaire consisted of 64 questions. The first set of questions addressed basic information about the provider related to their medical credentialing (MD, DO, NP, or PA), years of experience, area of practice, and the age ranges of patients they see. The second group of questions addressed typical knowledge regarding hospice, its uses, and services provided to determine baseline knowledge. The last set of questions discussed the provider patient population chronic illness status, referral practices, and perceived barriers that primary care providers have to making hospice referrals. All questions were reviewed and approved by the project's content expert. Objective 2: Develop Educational Module The second objective was to develop a learning module regarding hospice and its services that addressed the barriers identified by both hospice providers and PCPs. Commonalities and differences in hospice provider and PCP perceptions of barriers and knowledge deficits pertaining to, and making referrals for, hospice services were noted. This information was consolidated and formed into a learning module. This module incorporated the key features and information about hospice that is needed for appropriate referral to hospice service. Special attention was given to aspects of information that identified deficits in education. Additional IMPROVING BARRIERS TO HOSPICE 19 education addressed barriers that were identified in the third section of the questionnaire. The learning module provided resources for further information and education on hospice. Module formatting and content was evaluated by content expert. Suggestions for revision were addressed and implemented into the final module (see Appendix E). Objective 3: Improve Primary Care Providers' Knowledge of Hospice The third objective was to improve PCPs' knowledge of hospice and its services. The educational module created in objective 2 was distributed to the original primary care providers who completed the pre-education questionnaire. A post-education questionnaire (see Appendix F) containing the same information as section 2 of the pre-education questionnaire was distributed via email by RedCap®. Additional questions related to evaluation of the module, its content, and format were also included. Pre- and post-education questionnaire results were analyzed and evaluated to determine if an improvement of knowledge was gained after watching the module. Objective 4: Disseminate Findings The final objective was to disseminate the final results of the project to the providers, students and faculty of the university, at the College of Nursing DNP project poster fair. Data collected from the questionnaires was consolidated and presented via poster presentation (see Appendix G). A second poster presentation was planned for the 2017 Snowbird CME Conference in Utah. Evaluation In order to ensure that the project was successful, each objective was evaluated. Final approval from faculty members and the IRB confirmed the project was exempt and was viable and met requirements for a DNP project. Approval was received for both questionnaires for IMPROVING BARRIERS TO HOSPICE 20 hospice and primary care providers by the content expert. The questionnaires were emailed to the participating providers and results received back via the RedCap portal. The evaluation of each objective was based on successful completion of the outlined implementation plan. Objective 1: Assess Providers' Use, Perceptions, and Knowledge of Hospice The first objective required the successful development of a pre-education module questionnaire that collected pertinent provider demographic information, pertinent hospice related knowledge based questions, and open ended questions that evoked perceived barriers to hospice referral making. The pre-education module questionnaire was first approved by content experts prior to delivery to participants. The effectiveness of the pre-education module questionnaire was evaluated through the completion of the questionnaire by providers. A total of 68 providers were invited to participate in the study and sent the pre-education module questionnaire. This included 16 hospice providers and 52 PCPs. The pre-education module questionnaire was identical for both sets of providers. The purpose of evaluating responses from both PCP and hospice providers was to gain two perspectives on gaps that exist in referral practices and potentially general hospice knowledge. Results of the questionnaire were anonymous. To facilitate matching pre- and post-education questionnaire results, each participant was asked to create a unique 5-character identification consisting of one letter then four single digit numbers (ex. A1234). After receiving questionnaire responses back, the data was extracted via the Redcap data export tool into an excel spreadsheet for easy comparison of results both between PCPs and between PCPs and hospice providers. Results of the pre-education module questionnaire were used to accomplish the development of the education module content in objective 2. A total of IMPROVING BARRIERS TO HOSPICE 21 19 (28%) pre-educational module questionnaires were returned of which 9 (13% of total, 56% of hospice only) were hospice providers and 10 (15% of total, 19% of PCP only) were PCPs. Of PCP participants (n=10), MDs and NPs represented the majority with each provider type representing 40% of the total population group. Family practice represented 60% of participants while 40% were in adult only practices. Most (40%) reported practicing 6-10 years. Ages ranged from 20 to 69 years old with the majority (50%) were between 30-39 years old. The majority of participants were male (60%) and Caucasian/white (100%). Of hospice participants (n=9), most (56%) were NPs followed by MDs (33%). All (100%) currently practiced in hospice services. The majority (44%) had been practicing 6-10 years. Ages 30-39 represented most (44%) of hospice participants. The majority of participants (78%) were female; 67% were Caucasian/white and 22% were Hispanic. The 2nd set of questions (12 in total) utilized a 6-point Likert scale ranging from strongly disagree (reported as 0) to strongly agree (reported as 5) to access provider's ideals toward hospice, palliative care, and advanced care planning. Primary care provider mean responses with calculated standard deviation (SD) for each category were: knowing patient wishes more important for specialist than PCP 3.10 +2.02SD; comfort having advanced care planning discussions 4.00 +0.94SD; takes too much time to discuss advanced care planning 2.40 +1.84SD; feel comfortable giving poor prognosis to patient 2.90 +1.6SD; advanced care planning is too upsetting to patients 2.5 +1.78SD; believe patients should initiate discussion on advanced care planning 2.1 +1.79SD; advanced care wishes are rarely honored 1.9 +1.60SD; been in clinical situation where an advanced care directive was beneficial 4.10 +1.52SD; palliative care and hospice are the same 1.11 +1.05SD; hospice is type of palliative care but not all palliative care is hospice 4.10 +1.1SD; palliative care for patients only with <6 months to live IMPROVING BARRIERS TO HOSPICE 22 1.6 +1.71SD; purpose of palliative care is to procure advanced directives to ensure life-extending treatments cease 0.5 +0.53SD. A summary of both PCP and hospice section 2 mean responses with SD are listed in Appendix H. In all cases of responses, the hospice providers' mean responses were polarized to the strongly agreed/disagreed more than the PCP with smaller standard deviation values indicating less variation in responses from hospice providers compared to PCPs. Of the 12 questions, 5 had a difference of approximately 2 scale points between hospice and PCP responses. Of those 5 questions, hospice providers responded closer to the strongly disagree category compared to PCPs on questions regarding: takes too much time to discuss advanced care planning; knowing patient wishes more important for specialist than PCP; believe patients should initiate discussion on advanced care planning and; advanced care planning is too upsetting for patients. Hospice participants responded more toward strongly agree than PCPs on "feel comfortable communicating a poor prognosis to patients". The 3rd set of questions were used to assess basic knowledge of hospice, relationship of hospice to palliative care, and patient qualification for hospice. Providers answered either true or false to the questions with 0 representing true and 1 representing false. The PCP mean responses (with corresponding hospice responses) are summarized in Appendix I below. The most significant differences in responses from PCPs compared to the hospice providers included topics related to: lack of sufficient education in regards to hospice, its services, and particularly the referral process; patient/family resistance to hospice or advance care planning discussions; inadequate time to address such topics by providers; lack of standardized process in appointment routines; and insufficient practice or comfort level with having such discussions. The average PCP score based on all 23 questions was 77.0% +14.6SD compared to hospice providers 94.7% IMPROVING BARRIERS TO HOSPICE 23 +6.4SD indicating a deficiency in general hospice knowledge compared to those in the hospice community (see Appendix J). The final two sections collected data on when discussions of advanced care planning, hospice referrals, and palliative care referrals are believed to be occurring and when they are perceived to actually be occurring in relation to patients given a life-limiting diagnosis. Time interval options ranged from disease onset to near death. A summary of results can be found in Appendix K. This section also included information on numbers of referrals that the PCPs had made in the past 6 months to hospice and/or palliative care. The mean number of hospice referrals was 6.3 with a minimum response of 0 and max response of 60. Palliative care referrals averaged at 3.5 with a minimum of 0 and maximum of 30. To conclude, the pre-education module questionnaire included three free response questions. These included asking respondents to list their top three reasons they did not refer older adult patients to hospice services (if hospice provider, top three reasons PCPs do not refer older adult patients to hospice services); asking what would increase appropriate referrals to hospice for older adults in the primary care setting; and asking for additional comments they had to share. Out of 19 providers, 18 providers completed the free text responses (PCP n=10, Hospice n=8). Responses were divided into similar categories of which seven main categories were identified seen in Appendix L. The seven categories of barriers in order of highest identified to lowest identified were: 1) provider education deficiency with hospice/ACP/palliative care, 2) patient/family resistance, 3) inadequate time to address topic, 4) lack process or priority for discussion, 5) low comfort level in having discussions, 6) believe discussion is the role of specialists, and 7) patient population doesn't meet criteria. Remaining IMPROVING BARRIERS TO HOSPICE 24 responses were placed in the category other. Responses in each category were fairly equal between hospice and PCPs. In response to what would improve hospice referrals, four main responses were noted: better education for hospice/palliative care/advanced care planning in both schooling and continuing education requirements; better and earlier education to patients and families related to advanced care planning; changing societies perceptions of hospice and advanced care planning; and better communication between PCPs and specialty providers regarding patient's prognosis and disease status. Providers had opportunity to provide feedback on the pre-educational module questionnaire itself. No concerns or complaints regarding the material or questions was noted. The data provided useful data that was utilized in objective two. Objective 2: Develop Educational Module For the second objective, an educational module was developed based on the results of the pre-educational module questionnaire. Although only eight topics from the survey showed significant knowledge gaps in the PCP group, all 23 questions were address in the module. In addition the second section contained a summary of the identified barriers as listed in the above objective with a variety of ideas to address those barriers. The module was created as an adaptation of a template module provided by the National Hospice and Palliative Care Organization (NHPCO). The module was limited to seven minutes given the provider time constraints for viewing and participation. The module was approved by the content expert. Any recommendations for change were made and implemented in the final module (see Appendix E). Objective 3: Improve Primary Care Providers' Knowledge For the third objective, a post-education questionnaire was created using the online portal in Redcap. This consisted of previously approved questions from the pre-education IMPROVING BARRIERS TO HOSPICE 25 questionnaire section 2, related to basic hospice related information and knowledge. The questionnaire also contained the unique identifier and demographic information for matching pre- and post-results. Both the approved educational module and post-education questionnaire were delivered to the original participating PCP participants via RedCap. Post-education questionnaire results were collected and downloaded utilizing the data export tool. Preeducation and post-education questionnaire responses were matched using the unique identifier. Means and standard deviations were calculated. A paired two-sample t-Test was used to calculate if the change in scoring was significant in improving knowledge. Results of the posteducation module including comparison are found in the result section. Objective 4: Disseminate Findings For the final objective, the completed educational presentation and results were given to faculty chairs. A handout was developed and approved by content experts and chair representing finding of the project. A presentation poster was developed (see Appendix G), approved by content expert and faculty chair, and delivered to fellow students and faculty. A project abstract submission for external poster presentation was sent to the 2017 Snowbird CME Conference with pending approval and hopeful disseminated of findings (see Appendix M). Comments from attendees at both school and professional conference events regarding the project content were collected and taken into account for future presentations. Objectives: 1. Assess both hospice providers' and primary care providers' perceptions of what barriers exist for primary care providers in referring older adults to hospice, particularly primary care provider knowledge Implementation: Focal teaching points from a literature review. Develop questionnaire to determine perceptions of PCP barriers to hospice referral. Apply for IRB approval Evaluation: Questionnaire approved by content experts and chair IRB approval received Questionnaire emailed to identified hospice/PCP participants. IMPROVING BARRIERS TO HOSPICE 26 deficits surrounding hospice referral. Send questionnaire to participants via email. (N=11 each group) 2. Develop a learning module regarding hospice and its services that addresses the barriers identified by both hospice providers and primary care providers. Develop learning module including key information regarding hospice services and identified barriers. Identify and include further resources for provider education. Module developed and approved by content expert and chair. Feedback on the presentation received and necessary revisions made. 3. Improve primary care provider's knowledge of hospice and its services. Deliver post-questionnaire to PCPs. Collect responses and compare results to determine if there was a knowledge gain after watching learning module. Post-questionnaire approved by content experts and chair. Module emailed to same providers that participated in pre-questionnaire. Pre- and post-questionnaires compared. Provider knowledge improved. 4. Disseminate the collected information at student poster presentation and submit to professional conference. Consolidate information into poster presentation. Provide revised educational presentation to appropriate faculty Deliver presentation at future professional conference Educational presentation given to faculty. Presentation delivered at conference. Comments from attendees about the presentation received. Results Pre-education module questionnaire results are thoroughly discussed in the evaluation section under objective 2. The developed educational module was sent to the 10 PCP respondents of the pre-educational module questionnaire. Correspondence included a link to the education module and a post-educational module questionnaire. A total of 7 out of the 10 PCPs returned post-educational module questionnaires (70% return rate). The average score on the pre-education module questionnaire for the final seven participating PCPs was 72.05% +14.8SD. IMPROVING BARRIERS TO HOSPICE 27 After reviewing the education module and taking the post-educational module questionnaire, the average score was 97.5% +4.93SD. This represented a 25% increase in average scores from the pre to post-educational module questionnaires. A paired two sample t-Test was applied to the pre- and post-education questionnaire results which showed a significant increase of provider knowledge in relation to hospice with a p-value of 0.003. A complete table, graph, and statistical measures are found in Appendix N. When asked if the module helped to increase knowledge of hospice and its services responses ranged from somewhat agree to strongly agree. Additional information the providers would have liked included: more information on tools that can be used to determine an estimate of how long a person might live given a specific diagnosis; more about initiating palliative care; specific examples on how to incorporate these topics into practice; and information on the current rates of hospice referrals in the specialty arena compared to primary care arena. Limitations/Barriers The sample for this project was a non-probability convenience sample, which means it may not be representative of the experiences of a larger population of PCPs or of hospice providers. Additionally, the small sample population included in this project may also act as a limitation as transferability to the larger arena of primary care may produce varying results. That said, the findings and conclusions of the project largely align with those previously reported the research literature. Recommendations This project served to explore and address barriers that PCPs feel inhibit their ability to properly and adequately identify hospice needs of their adult patients and ultimately make appropriate referrals of these patients to hospice. This project has demonstrated that a number of IMPROVING BARRIERS TO HOSPICE 28 barriers exist which limits the referral practice. This includes, but is not limited to, a deficit in proper formal education surrounding hospice and related subjects such as palliative care and advanced care planning. Participants in this project demonstrated that there is benefit in further education related to hospice providers and it in deed increased PCPs understanding of hospice and the referral process. While outside the confines of this project, the ultimate goal is to increase appropriate/timely hospice referrals in the primary care setting. It would be anticipated that if similar educational modules were administered to and utilized by a more widespread group of PCPs correlating results would be seen. It is recommended that primary care clinics serving adult patients should adopt similar continuing education modules to improve referral practices. In addition, it would be suggested that physician, nurse practitioner, and physician assistant schools incorporate required education on this topic to facilitate better understanding of hospice before clinical practice. DNP Essentials Essential number II, of the Essentials of Doctoral Education for Advanced Nursing Practice, focuses on organizational and systems leadership for quality improvement and systems thinking (American Association of Colleges of Nursing, 2006). This essential is one of several essentials identified that relate to this scholarly project. This project addressed this essential by investigating current practice methods utilized in primary care settings relating to hospice referral processes and provider barriers to referring to such services for the older adult population (>65 years old). This was done by surveying primary care providers in family/internal medicine practices, identifying barriers, including knowledge gaps present, and developing an educational module to address the identified gaps and barriers. IMPROVING BARRIERS TO HOSPICE 29 By understanding current practices and barriers, interventions can be devised and initiated into practice, such as creating learning modules that address identified barriers and provide general education material. These modules were dispersed to the surveyed providers, as well as others. Projects such as this help to identify small changes that can be made in local clinics that will affect their patient population. With further development, these local or clinic specific modules may develop into a larger organizational/system wide resource that may increase the quality and level of care, level of excellence in practice, and overall patient satisfaction. Conclusions Hospice is a vital resource that has potential for positively affecting older adults in need of its services. Many primary care providers (PCP) are reluctant to refer older adult patients (>65 years old) for hospice services, even though these services have shown to improve end-oflife care. This reluctance in referring is a problem because many older adults who would potentially qualify for hospice services are not being referred and, as a result, are not benefitting from hospice services, or only receiving services for a portion of the time for which they would qualify. The end result is underutilization of hospice services, which undermines delivery of high quality care to older adult patients. Barriers exist in the primary care setting that lower the rate of hospice referrals being made in this patient care setting. Determining current barriers to appropriate and timely hospice referral making in the primary care setting is necessary to improving end-of-life care. The purpose of this project was to determine barriers to hospice referral in the primary care setting (e.g. knowledge gaps, lack of resources, poor patient education, etc.) to improve identified gaps and address barriers identified. The future goal was to increase IMPROVING BARRIERS TO HOSPICE 30 appropriate/timely utilization of these service therefore improving end-of-life experience for both patient that qualify and their caregivers. Development and dissemination of an educational module helped to close knowledge gaps, and hopefully, partially remove barriers to making hospice referrals for this population in this setting. Despite the success of this project, continuing efforts must be made to further improve hospice education of PCPs and address the barriers that exist in the primary care setting. IMPROVING BARRIERS TO HOSPICE 31 References Finestone, A. J., & Inderwies, G. (2008). Death and dying in the US: the barriers to the benefits of palliative and hospice care. Clinical Interventions in Aging, 3(3), 595-599. Hutcheson, A. (2011). Hospice care in the United States. Prim Care, 38(2), 173-182, vii. doi:10.1016/j.pop.2011.03.002 Kirolos, I., Tamariz, L., Schultz, E. A., Diaz, Y., Wood, B. A., & Palacio, A. (2014). Interventions to improve hospice and palliative care referral: a systematic review. J Palliat Med, 17(8), 957-964. doi:10.1089/jpm.2013.0503 National Council on Aging. (n.d.). Healthy Aging Facts. Retrieved from https://www.ncoa.org/news/resources-for-reporters/get-the-facts/healthy-aging-facts/ National Hospice and Palliative Care Organization. (2014). 2014 Facts and Figures. Retrieved from http://www.nhpco.org/sites/default/files/public/Statistics_Research/2014_Facts_Figures.p df Obermeyer, Z., Makar, M., Abujaber, S., Dominici, F., Block, S., & Cutler, D. M. (2014). Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA, 312(18), 1888-1896. doi:10.1001/jama.2014.14950 Ogle, K., Mavis, B., & Wang, T. (2003). Hospice and primary care physicians: Attitudes, knowledge, and barriers. American Journal of Hospice & Palliative Care, 20(1), 11. Snyder, S., Hazelett, S., Allen, K., & Radwany, S. (2013). Physician knowledge, attitude, and experience with advance care planning, palliative care, and hospice: results of a primary care survey. Am J Hosp Palliat Care, 30(5), 419-424. doi:10.1177/1049909112452467 IMPROVING BARRIERS TO HOSPICE 32 Stevens, K. (2004). ACE star model of knowledge transformation. Academic Center for Evidence-based Practice. Retrieved from http://nursing.uthscsa.edu/onrs/starmodel/ U.S. Census Bureau Population Division. (2015). Monthly Population Estimates for the United States: April 1, 2010 to December 1, 2016. IMPROVING BARRIERS TO HOSPICE 33 Figures IMPROVING BARRIERS TO HOSPICE Figure 1. ACE Star Model of Knowledge Transformation 34 IMPROVING BARRIERS TO HOSPICE 35 Appendices IMPROVING BARRIERS TO HOSPICE Appendix A: DNP Project Proposal PowerPoint Presentation 36 IMPROVING BARRIERS TO HOSPICE 37 IMPROVING BARRIERS TO HOSPICE 38 IMPROVING BARRIERS TO HOSPICE 39 IMPROVING BARRIERS TO HOSPICE Appendix B: IRB Exemption Letter 40 IMPROVING BARRIERS TO HOSPICE Appendix C: Pre-Education Questionnaire 41 IMPROVING BARRIERS TO HOSPICE 42 IMPROVING BARRIERS TO HOSPICE 43 Appendix D: Participant Recruitment Letter <<Date>> <<Name of potential participant>> <<Address>> <<City, State, Zip>> Re: Improving Barriers to Hospice Referrals for Older Adults in the Primary Care Setting Dear <<Name of potential participant>>: I am writing to let you know about an opportunity to participate in a research study about referral practices in the primary care setting and what barriers exist in this setting to referring older adult patients for such services. The study is being conducted by myself, Andrew Cardon, a Doctorate of Nursing Practice candidate at the University of Utah College of Nursing. This study will utilize an online questionnaire to assess knowledge of hospice and its services, current referral practices, and perceived barriers to making such referrals in the primary care setting. Collected information will be utilized to identify the most prominent barriers. A learning module will be developed and sent back to participants to view with a follow-up questionnaire to be completed. Contact information for you and your clinic was obtained by utilizing public record via online and phone book searches for family practice clinics and providers since these types of providers and clinics are the focus of the study. No private information has been obtained beyond the public records indicated above. In seven to ten days you will be contacted by phone as to your availability to participate in this study. If before the time of the phone call you would like to opt out of participating in this research you may contact me via phone or email (provided below) and no further contact attempts will be made. You may also express interest or further information earlier than next contact via the same means as stated previously. If you would like to participate a valid email address will be collected and a consent form and questionnaire will be sent via electronic means. An agreement to be contacted or a request for more information does not obligate you to participate in this study. You may opt out of the study by not responding to the email or any time while taking the questionnaire until the questionnaire is submitted back. If you would like additional information about this study or to opt out of further contact, please call Andrew Cardon at 801-361-0736 or via email at [e-mail]. Thank you again for your time and considering this research opportunity. I look forward to the chance to make you a part of this study. Signature: Andrew Cardon, BSN-RN, DNP-S IMPROVING BARRIERS TO HOSPICE Appendix E: Educational Module 44 IMPROVING BARRIERS TO HOSPICE 45 IMPROVING BARRIERS TO HOSPICE 46 IMPROVING BARRIERS TO HOSPICE 47 IMPROVING BARRIERS TO HOSPICE 48 IMPROVING BARRIERS TO HOSPICE 49 IMPROVING BARRIERS TO HOSPICE 50 IMPROVING BARRIERS TO HOSPICE 51 IMPROVING BARRIERS TO HOSPICE 52 IMPROVING BARRIERS TO HOSPICE 53 IMPROVING BARRIERS TO HOSPICE 54 IMPROVING BARRIERS TO HOSPICE 55 IMPROVING BARRIERS TO HOSPICE Appendix F: Post-Education Questionnaire 56 IMPROVING BARRIERS TO HOSPICE Appendix G: Final Poster Presentation 57 IMPROVING BARRIERS TO HOSPICE Appendix H: Pre-Education Questionnaire Section 2 Responses 58 IMPROVING BARRIERS TO HOSPICE Appendix I: Pre-Education Questionnaire Section 3 Responses 59 IMPROVING BARRIERS TO HOSPICE Appendix J: Pre-Education Questionnaire Section 3 Results 60 IMPROVING BARRIERS TO HOSPICE Appendix K: Believed Should vs Actual Consults Hospice, Palliative Care, ACP 61 IMPROVING BARRIERS TO HOSPICE 62 IMPROVING BARRIERS TO HOSPICE 63 IMPROVING BARRIERS TO HOSPICE Appendix L: Pre-Education Questionnaire Free Response 64 IMPROVING BARRIERS TO HOSPICE 65 Appendix M: 2017 Snowbird CME Abstract Submission IMPROVING BARRIERS TO HOSPICE REFERRALS FOR OLDER ADULTS IN THE PRIMARY CARE SETTING Andrew Cardon, BSN, DNP-Student Purpose: The project purpose was to determine barriers to hospice referral in the primary care setting (e.g. knowledge gaps, lack of resources, poor patient education, etc.) to increase appropriate/timely utilization of these service therefore improving end-of-life experience for both patient that qualify and their caregivers. Objectives: Objectives of this project were to 1) assess both hospice providers' and PCPs' perceptions of what barriers exist for primary care providers in referring older adults to hospice, particularly PCP knowledge deficits surrounding hospice referral; 2) develop a learning module regarding hospice and its services that addresses the barriers identified by both hospice providers and PCPs; and 3) improve PCPs' knowledge of hospice and its services. Method/Results: A questionnaire was developed to assess referral barriers, and was delivered to both PCPs (n=52) and hospice providers (n=16). Hospice responses (n=9) and PCP responses (n=10) were collected. Based on survey findings, which found lack of education regarding hospice and unfamiliarity with the hospice referral process among top barriers, an educational module was developed. The educational module with post-education questionnaire was sent to the 10 PCP respondents of the pre-education questionnaire. A total of 7 out of the 10 PCPs returned post-education module questionnaires (70% return rate). The average pre-education module questionnaire for the final seven participating PCPs was 72.05% +14.8SD. After reviewing the education module and taking the post-educational module questionnaire, the average score was 97.5% +4.93SD. This represented a 25% increase in average scores from the pre- to post-educational module questionnaires. A paired two sample t-Test was applied to the pre- and post-education questionnaire results which showed a significant increase of provider knowledge in relation to hospice with a p-value of 0.003. Conclusion: Barriers exist in the primary care setting that lower the rate of appropriate hospice referrals made in primary care. Determining current barriers to appropriate/timely hospice referral making in the primary care setting is necessary to improving end-of-life care. The future goal for this project is to increase appropriate/timely utilization of these service therefore improving end-of-life experience for both patient that qualify and their caregivers. Development and dissemination of an educational module helped to close knowledge gaps, and hopefully, partially remove barriers to making hospice referrals for this population in this setting. Despite success of this project, continuing efforts must be made to further improve hospice education of PCPs and address the barriers that exist in the primary care setting. IMPROVING BARRIERS TO HOSPICE Appendix N: Final Results Pre- vs Post-Education Results Comparison 66 IMPROVING BARRIERS TO HOSPICE 67