Quality Insights will launch a new project in 2023 with the Palliative Care Center and Palliative Care of Southern WV as part of the WV Serious Illness Care Collaborative. The goal of the Serious Illness Transition Support (SITS) project is to improve access to palliative care in Nicholas, Fayette and Raleigh Counties and reduce the need for unnecessary hospitalization. An environmental scan of Medicare data was conducted to assess the number of emergency room visits, readmissions and hospitalizations in patients with heart failure, chronic kidney disease and chronic obstructive pulmonary disease.
Many different educational tools have been developed for provider and patient education. They include a screening tool for providers to identify patients with serious illness who may benefit from an extra layer of support when transitioning back to the community. These patients will be introduced to the SITS program with some educational materials and will be invited to watch a Powtoon ‘Palliative Care and Oranges.’ This short video explains how palliative care can help just as a basket can hold all your oranges when you can’t carry them alone.
The SITS teams will make home visits and are able to help with medication management; patient and caregiver education; advance care planning; and care coordination. They will also make referrals to community resources to ensure that social needs are met.
The outcomes that will be measured are patient/caregiver satisfaction; readmission within 30 days; emergency room visits; and hospitalizations. Data will be compared between patients who agree to the SITS program and those who opt for regular care.