ALIGN: A Focused Palliative Care Intervention for Cancer Patients Discharging to Skilled Nursing Facilities
My pilot work, funded by the Palliative Care Research Cooperative, showed that hospitalized patients with advanced cancer and functional decline who discharge to a skilled nursing facility (SNF) have high 6-month mortality, high readmission rates, and rarely receive future cancer directed therapy. These patients represent an ideal population that would benefit from palliative care consultation however palliative care service delivery models in the SNF setting are lacking. ALIGN, (Assessing and Listening to Individual Goals and Needs), is a promising palliative care social work intervention that follows patients and caregivers during their SNF stay and for 45 days after SNF discharge. The intervention focuses on defining patient and caregiver goals, facilitating communication between patients and their care teams, and developing patient-centered care plans that accompany patients across future care transitions. My proposed study aims to evaluate how ALIGN can be implemented most effectively for patients with advanced cancer discharging to a SNF after an acute care hospital within a 6-county catchment area of our academic tertiary care center. This work will examine a targeted palliative care intervention for medically complex patients with impending poor outcomes in the post-acute care space – a setting in our health care system that lacks a robust palliative care delivery model. This information will be critical to understand in order to further develop and refine this innovative delivery model so that it can be successfully implemented in real world practice and further evaluated for efficacy.
Singh, MD, is an Assistant Professor in the Division of Hospital Medicine at
the University of Colorado. She attended medical school at Oregon Health and
Science University and completed her Internal Medicine internship and residency
at the University of Wisconsin Madison. She currently serves as a Physician
Advisor for the University of Colorado Health system. Dr. Singh is interested
in improving palliative care outcomes for patients with advanced cancer and
progressive functional decline in the post-acute care setting by developing and
implementing effective person-centered interventions that interrupt the cycle
of repeated institutionalization towards the end of life. Her goal is to impact
health care policy reform moving health care delivery systems to better serve
the needs of patients with serious illness and limited rehabilitation potential
at the end of life.