Qualitative Description of Palliative Case Management: Implications for Developing Best Practices in the VA System

Riopelle DD, Steckart JM, Magner ML, Cox NC, Rosenfeld KE. Qualitative Description of Palliative Case Management: Implications for Developing Best Practices in the VA System. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.

Related HSR&D Project(s)

• IIR 02-294 – Randomized Trial of Care Management to Improve End of Life Care

Objectives: To generate a detailed description of palliative case management activities and assess the feasibility of developing protocols for a VA multi-site evaluation. Methods: Three palliative care case managers were shadowed in four-hour blocks for an average of 15 hours each as they carried out their daily duties. Observation periods were distributed to maximize exposure to a variety of patients and interactions. Detailed notes of shadowing activities were transcribed and entered into a software program designed to assist with qualitative analysis. Each shadowing session was coded by two researchers. Codes were merged and analyzed for inter-rater reliability. Initial coding domains and codes were developed based on a government report on end-of-life care and outcomes. Relevant codes that emerged were added as needed. Notes were coded for domain, scope, frequency, and duration of activities. Overarching themes were identified. Results: The majority of activities fell within the domains of continuity and coordination of care, patient psycho-spiritual well-being, patient physical well-being, and hospice care. The most frequently coded activities were scheduling and coordinating appointments, consulting with providers about a patient’s care, obtaining, reviewing, and exchanging patient information. Activities took place in a variety of settings throughout the VA facility: hospital wards, outpatient clinics, and nursing homes. Case managers interacted with a wide-range of other health care staff and both VA and non-VA administrative personnel. Implications: While developing a case management tool kit is feasible, creating specific case management protocols may prove difficult given the wide range of activities and patient needs inherent to palliative case management. Providing case managers with strong administrative support would enable them to focus more on psycho-social and palliative patient needs as opposed to administrative tasks. Impacts: The veteran population is aging rapidly, and costs associated with providing care in the last months of life are escalating. While establishing rigorous palliative case management protocols may not be practical, the creation of guidelines can facilitate the development of case management programs which will promote best practices, decrease costs, and increase the quality of care for veterans at the end of life.