| Description |
Background: Early palliative care enhances quality of life, alleviates symptoms, and supports holistic care. However, primary care physicians (PCPs) often fail to inform patients about the benefits of palliative care, with uninsured, non-English-speaking, and immigrant patients facing the most significant disparities in referrals. Early palliative care improves symptom management, quality of life, and reduces healthcare costs. Despite patients being more likely to engage in palliative care when referred by their PCP, referral rates remain low, particularly among immigrant populations. Barriers include limited PCP training, misconceptions about palliative care, and discomfort in discussing it. Local Problem: The challenges that preclude PCPs from referring to PC are exacerbated at an urban family practice clinic where 90% of patients lack commercial insurance, introducing cultural and financial complexities. A new electronic health record (EHR) referral system was implemented at the project site; however, PCPs lack sufficient training in culturally sensitive communication, identifying palliative candidates, and using the referral system. This quality improvement project aimed to enhance PCP awareness and increase palliative care referrals. Methods and Interventions: The Johns Hopkins Evidence-Based Practice model guided this quality improvement initiative, along with several Plan-Do-Study-Act (PDSA) cycles which allowed for multiple rounds of interventions. PCP awareness was assessed through a pre-intervention survey, and referral data was compared to the period 12 months prior to account for seasonal variation. Data tracked total referrals, uninsured patients, non-English speakers, immigrant patients, and those meeting Center to Advance Palliative Care (CAPC) criteria for palliative care referrals. A stakeholder-developed toolkit promoted cultural humility, raised awareness, and streamlined referrals. Toolkit resources, including the CAPC webpage and cultural humility guides, were accessible via QR codes in high-visibility areas. Feedback was collected biweekly for refinement. Additionally, Medicare and Medicaid-friendly referral options were integrated into the clinic's EHR to ensure patient accessibility. Results: Findings indicated that 879 active clinic patients had at least one palliative care-appropriate diagnosis, and 253 had two or more diagnoses per CAPC guidelines. Despite these large numbers, PCPs had not made any palliative care referrals had been made by PCPs in the past year. Following the implementation of the toolkit, six referrals were made (Figure 2). Furthermore, there was an improvement in provider awareness of PC (44.44% following the toolkit vs. 25% prior). Conclusion: An increase in palliative care referrals occurred, revealing previously unrecognized barriers to patient communication and access, particularly among uninsured, non-English-speaking, and immigrant populations. The following steps involve exploring palliative care discussions in primary care from the patient's perspective and identifying communication barriers between outpatient palliative care specialists and the primary care providers who place referrals. |
