The National Palliative Care Research Center

Curing suffering through palliative care research.


Stacy Fischer MD

Associate Professor

University of Colorado School of Medicine

Grant Year
Grant Term
2 years
Grant Type
Pilot & Exploratory Project Support Grant

Project Description
ALIGN: Integrating Palliative Care Social Workers into Sub-Acute Settings

Nearly all adults will experience progressive chronic illness and functional decline in the years before death. Recurrent hospitalizations are often followed by a stay in a sub-acute rehabilitation facility (SNF rehab) before patients can safely transition back to independent living. One third of older adults will utilize SNF rehab in the last six months of their life and 10% of them will die there. Hospice care is essentially non-existent in this setting and palliative care has very low penetration. Few health professionals working in the SNF rehab setting have any training in palliative care. In response to this care gap, we have developed a palliative care social worker (PCSW) led intervention aimed to improve communication, provide support to patients and caregivers, and align goals of care with the medical plan. The ALIGN (Assessing & Listening to Individual Goals and Needs) intervention addresses the combination of medical, functional, psychological, and social goals related to patient care and targets those patients at high risk for poor outcomes. ALIGN integrates PCSW approaches and resources into sub-acute settings, establishing an evidence based-intervention strategy that will enhance interdisciplinary participation in care across multiple settings. The specific aims of this pilot are to 1) determine the feasibility of conducting a trial of ALIGN in older persons admitted to SNF rehab and their caregivers (SA1) using a pragmatic step wedge design and 2) determine the effect of ALIGN vs. usual care on the primary patient (quality of life) primary caregiver (burden) and secondary (health care utilization) outcome measures (SA2). The long-term goal of this research is to conduct a full-scale trial of the ALIGN intervention. This evidence based, theory driven intervention has the potential to lead towards a more comprehensive approach resulting in better outcomes for high-risk older adults facing serious illness and their families.


Dr. Stacy Fischer is an Associate Professor in the Division of General Internal Medicine at the University of Colorado School of Medicine. Her research has focused on improving palliative care focused outcomes for underserved populations using innovative approaches to address work force shortages. She has developed and tested a lay navigator intervention for Latinos with advanced cancer and is currently testing the intervention for patients with serious non-cancer illness. This NPCRC grant will be a critical step towards testing a social work led intervention to improve palliative care focused outcomes for patients in subacute nursing facilities. She has also received funding from the National Institute of Aging, American Cancer Society, and National Institute of Nursing Research.