Nursing Home Palliative Care Referral Process, Barriers, and Proposed Solutions: A Qualitative Study

Abstract

Despite evidence that specialized care for seriously ill nursing home (NH) residents is needed, barriers to accessing palliative care (PC) remain. A significant issue is the complexity of the referral process that inhibits timely and equitable access to care. This qualitative descriptive study explored the PC referral process in NHs. Using rapid qualitative analysis with semi-structured interview data from NH staff, primary care, and specialty PC providers (N = 17) in six states, this study outlines a multistep referral process along with barriers and proposed solutions. Key recommendations include comprehensive PC education program development, implementation of an evidence-based PC screening tool, and the holistic integration of PC services in NHs.

Introduction

As the US population ages and their healthcare treatments advance, more adults living with serious illness receive post-acute and long-term care in nursing homes (NHs). Managing symptoms and planning for care in this context is complex and time-consuming, with poor symptom management leading to unnecessary suffering and reduced quality of life (Stephens et al., 2018). Inadequate discussions about care goals and treatment preferences can lead to misaligned care planning. These challenges are compounded in NHs, where staff report little end-of-life care knowledge and need for capacity building to deliver high quality palliative care (PC) (Unroe et al., 2015).

Palliative care plays a crucial role in NHs, aiming to enhance the quality of life for residents with serious illness and their families (Ersek et al., 2022; National Academies of Sciences & Medicine, 2022). Palliative care offers a holistic approach, focusing on alleviating suffering and enhancing comfort, regardless of illness stage or treatment choices (National Consensus Project for Quality Palliative Care, 2018). Researchers and clinicians describe two delivery models of PC (Payne et al., 2022). Primary PC encompasses basic symptom management, advance care planning, anticipatory guidance, and addressing spiritual and psychosocial needs. It is typically provided by generalist providers with enhanced skills in PC, such as primary care NH specialists and geriatricians. These providers possess some specialist PC knowledge, but do not provide PC as the primary aspect of their practice (Payne et al., 2022). Specialty PC is needed to meet more complex patient needs including complex symptom management, intricate family dynamics, and specialized ethical and legal issues. Specialty PC is provided by healthcare professionals with specialist PC training and certification, whose exclusive role is to manage patients PC needs (Payne et al., 2022).

Despite the potential for effective collaboration between primary care providers and specialists PC providers to meet the comprehensive needs of NH residents, PC remains underutilized in NHs (National Academies of Sciences & Medicine, 2022). Multiple barriers contribute to underutilization of PC in NHs, including prognostic uncertainty and lack of standardized screening processes and referral criteria (Cole et al., 2023; Rice et al., 2018). Nursing home registered nurses, administrators, primary care providers, and specialist PC providers have a critical role in the structure and process of PC referral for seriously ill NH residents. However, in-depth investigation of their perspectives around identification and referral processes for specialist PC have been largely omitted. Therefore, the objective of this study is to examine NH specialist PC consultation referral processes, identify associated barriers to referral, and explore potential solutions.

Methods

Study Design

This study applied a qualitative descriptive approach using semi-structured interviews with key individuals caring for NH residents. The study was reviewed by Colorado Multiple Institutional Review Board and determined to be exempt. This article adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guidelines (Supplemental Material) (Tong et al., 2007).

Participants and Recruitment

To reach a national sample, participants were recruited through professional organizations’ web-based list-serves (Gerontological Advance Practices Nurses Association, Hospice and Palliative Nurses Association), a closed Facebook group for nurse practitioners employed in the NH setting and using snowball sampling. Data collection was conducted from November 2022 to January 2023. Participants were eligible if employed as NH staff, NH provider, or PC provider, and had professional experience with PC referrals for NH residents. Recruitment continued until no new patterns or themes were identified indicating that saturation was reached (Hennink et al., 2017). Participation was voluntary; participants provided verbal informed consent prior to any research procedures.

Data Collection

The research team developed the interview guide using an iterative process guided by the Practical Robust Implementation Sustainability Model (PRISM) (McCreight et al., 2019). This framework allowed a systematic examination of relevant factors related to identifying and addressing PC needs in NH residents. The interview guide, previously published, was reviewed by a qualitative methodologist and refined prior to beginning data collection (Cole et al., 2024). The principal investigator (CSC) has experience with NH, PC, and qualitative research and conducted all interviews. Interviews began with a definition of PC to ensure a shared understanding of the concept being discussed. At outset, each participant was asked to describe a recent experience with a NH resident who would have potentially benefited from PC referral. Probes were used to elicit more information regarding the referral process including the identification of barriers. We did not ask participants directly about ways to improve the referral process but did probe further if participants spontaneously mentioned solutions to identified barriers. Interviews lasted an average of 33 minutes, were conducted by phone, audio recorded, professionally transcribed and de-identified. Participants provided demographic information post interview and received a $25 gift card for appreciation of their time.

Data Analysis

The principal investigator led the deductive rapid qualitative analysis (Nevedal et al., 2021). Transcripts were reviewed and participant responses to interview questions were summarized in a spreadsheet. All transcripts were iteratively reviewed and double coded by two team members (RB, AJ) to ensure coding consistency, accuracy, and completeness. Next, responses were grouped into categories reflecting the focus of each set of questions (e.g., process, barriers). Summary data for related sets of question responses were reviewed and a memo written summarizing themes by category across all participants. Memos were reviewed and validated by a second team member. Findings were cross-checked among the team and different interpretations were discussed until reaching consensus. Next, utilizing the referral process outlined by participants, we constructed a referral pathway. Finally, we placed reported barriers and proposed solutions at relevant points along this pathway.

Results

The seventeen study participants included NH staff (n = 3), NH primary care providers (n = 10), and specialty PC nurse practitioners (n = 4) from 6 states (Alabama, Indiana, North Carolina, New York, Nevada, Oregon) (Table 1). The mean age was 48 years, 13 (77%) were female, and 16 (94%) were white. Overall, each participant described the PC referral process in NHs and commonly encountered barriers. In addition, many participants spontaneously provided recommendations for ways to mitigate these barriers.

Table I.

Participant Demographics/Characteristics.

Participant characteristics	n = 17
	n (%)
Age, mean (SD)	48.3 (11.5)
Gender, female, n (%)	13 (76.5%)
Race, n (%)
White	16 (94.1%)
Black	1 (5.9%)
Ethnicity, n (%)
Hispanic/Latino	0 (0%)
Professional role, n (%)
NP, nursing home	9 (52.9%)
NP, PC	4 (23.5%)
Nursing home staff, (RN, MDS, administrator)	3 (17.7%)
MD	1 (5.9%)
Years in clinical practice, mean (SD)	13.7 (±12.1)
Years in clinical practice, range	1 to 38

Process of Specialist Palliative Care Referral in Nursing Homes

Participants described the PC referral process as a multistep process comprising four distinct stages: (1) Resident identification, (2) Eligibility assessment, (3) Consensus-building, and (4) Consultation (Figure 1). In subsequent sections, we provide descriptions of each stage and highlight barriers identified by participants and their proposed solutions.

Figure 1.

Process of PC referral in nursing homes with identified barriers and solutions as proposed by study participants.

Resident Identification.

The first step of the referral process involved identifying residents who could benefit from PC. Nearly all participants described this identification as an intuitive process without a designated individual responsible for screening. Instead, participants commonly characterized it as a decentralized process, allowing anyone to signal the need for considering PC for a particular resident. This observation would then be communicated to the nursing leadership or social worker for further evaluation. Participants emphasized the intuitive nature of resident identification, citing factors such as recognizing disease exacerbations or patterns of functional decline.

“We don’t have a formal screening per se. Our facility is a little different than most. We have a nurse practitioner in-house five days a week. So, we get to know the residents pretty well and we see that overall decline. The nursing staff also monitor for any overall decline or any discomfort, uncontrolled pain, but we do not have a formal screening process.” (Participant 14, NH Nurse Practitioner)

Only one NH primary care nurse practitioner mentioned their utilization of a mortality risk assessment, generated by the facility’s electronic health record system. This information was then used to inform discussions about goals of care and serious illness and was typically conducted upon admission and twice yearly.

Barriers.

The absence of standardized referral protocols and facility procedures created a significant barrier to identifying residents in need of PC. Participants highlighted that the lack of a designated individual responsible for screening led to an inconsistent approach. This enabled anyone to raise concerns about unmet PC needs, but often resulted in inconsistencies and hindered systematic prioritization. Consequently, this caused a reactive rather than proactive identification process. As a result, residents in advanced stages of illness were often identified late in their trajectory, with most referrals occurring at the end of life.

“Sometimes it’s too late before they refer them, they are actually at the end of life, instead of referring them earlier so that they and their families can benefit from the help they can get.” (Participant 01, NH Registered Nurse)

Additionally, NH primary care nurse practitioners observed that staff’s focus on tasks like medication administration sometimes diverted attention from recognizing the need for PC, impeding resident identification. This issue was exacerbated by a lack of recognition that identifying PC candidates should be a prioritized task integrated into care process. Furthermore, insufficient training for staff in recognizing PC indicators potentially contributed to failure to identify eligible residents.

“I feel like the nurses are too preoccupied with getting tasks done. They don’t even realize that this is as important as the task that needs to get done. And at the same time, they did not have the training to recognize the signs of this.” (Participant 10, NH Nurse Practitioner)

Solutions.

One potential solution to the issue of lacking a designated person and system for identifying residents for PC is to integrate this responsibility into the role of the Minimum Data Set (MDS) Coordinator. This registered nurse oversees the MDS Resident Assessment Instrument, which gathers extensive data on each resident’s health and social well-being. Since MDS assessments—required by the Centers for Medicare and Medicaid Services (CMS) for determining reimbursement rates and quality measures—are integral to developing personalized care plans, they provide an ideal framework for integrating PC identification responsibilities (Morris et al., 1990).

“I think the MDS [assessment] is a good way to identify someone who is declining. When you complete the MDS [assessment] from start to finish, it tells you where they have declined. It helps you see a bigger picture. They’re declining with their ADLs, they’re declining cognitively, they’re more depressed, they have more pain.” (Participant 04, NH Registered Nurse, MDS Coordinator)

This approach would leverage existing workflow and data, incorporating pertinent indicators like weight loss and cognitive decline, to identify those in need of PC. Additionally, after completion of each resident’s MDS assessment, facilities are required to hold a family care plan meeting. This meeting provides an ideal forum for openly discussing the results of screening with residents, families, and the care team, ultimately facilitating development of more comprehensive and resident-centered care plans.

Another suggested approach involves leveraging the care plan meeting as a temporal cue for the interdisciplinary care plan team. During these meetings, the team can proactively examine advance care planning documents and assess potential unmet PC needs by evaluating factors such as weight loss, declining mobility, and changes in cognitive status.

“At a care plan meeting, the nurse or the social worker could look, is there any advanced care planning documents? Has anything been talked about, discussed, or done prior. So that could be a flag. Because there are not many bedside nurses going to take the time to look for that.” (Participant 17, Palliative Care Nurse Practitioner)

Eligibility Assessment.

After residents were identified for PC by NH staff, the next critical step in the process was to assess eligibility for PC, typically by contacting the primary care provider for input. At this point in the referral process, providers could act to meet the identified needs of the resident (i.e., intensify symptom management) and/or recommend referral to PC. Families were not typically involved at this stage (but included at the next stage, consensus-building). The purpose of this eligibility determination stage was to make sure that residents met criteria for hospice or PC and had insurance that would pay for the cost of services.

“The nurse [practitioner] sees someone and she’s like, I don’t really know that they are appropriate for this, maybe you guys need to focus more on hospice services at this point or something like that. So, she’s very good about giving us feedback on when she feels somebody is not appropriate for PC services.” (Participant 06, NH Administrator)

Barriers.

Participants noted that during the eligibility assessment phase, post-acute short stay skilled nursing facility (SNF) residents are often ineligible for hospice care due to their pursuit of curative treatments and insurance constraints preventing dual payment for the same condition by both SNF and hospice services. Additionally, because hospice care and SNF care cannot be provided simultaneous for the same condition, this often leads to the mistaken belief that residents are also ineligible for PC during a post-acute SNF stay.

Moreover, participants highlighted a financial disincentive for facilities to offer hospice services. SNFs receive higher Medicare reimbursement for short-stay (<100 days) SNF residents compared to long-stay residents (>100 days), often paid privately or by state Medicaid programs. This creates a potential conflict of interest, as facilities may prefer keeping residents within SNF context rather than transitioning them to hospice care. Participants also pointed out a significant financial aspect acting as a disincentive to residents and families: Medicare covers facility room and board during a resident’s SNF stay. However, if a resident chooses hospice care instead of SNF care, Medicare ceases to cover facility room and board charge. Consequently, this cost shifts to the resident unless they have depleted their financial resources and qualify for Medicaid. This dilemma forces families to decide between SNF rehabilitation services and hospice care.

“Rehab oriented goals may not be appropriate, but they have to play the game because of Medicare, and at least getting some time for family to figure out the next step of how to take care of that person” (Participant 19, PC Nurse Practitioner)

“Sub-acute rehab is difficult because if you start even writing in your notes that they’re not doing well and that you think palliative [care] would be a good idea then that insurance might cut them [stop benefits] prematurely” (Participant 7, NH Nurse Practitioner)

Solutions.

Interestingly, some participants pointed out an intriguing aspect of this dilemma. They emphasized that SNF residents are well-suited for referral to non-hospice PC, primarily because such care is covered under Medicare Part B, which is distinct from post-acute SNF coverage provided under Medicare Part A. In essence, this distinction allows SNF residents to access PC without disrupting their ongoing SNF care. Moreover, residents who do not meet hospice requirements but qualify for PC, such as those with serious illnesses, could receive appropriate PC alongside SNF care. This is especially crucial given the acute and complex serious illness care required by many residents transitioning from acute care hospitals to post-acute care NHs.

“I am in a hospital setting, we try to send referrals for residents going to rehab that will be utilizing Medicare Part A skilled rehab benefits [post-acute SNF] even though we know they may not progress and do well in rehab, but that’s their only option. And they can’t have hospice care even though they may or may not be hospice eligible. We will send a referral but it’s up to that nursing home team to determine whether they feel it’s appropriate for PC.” (Participant 17, PC Nurse Practitioner)

Consensus-Building.

Following establishment of eligibility, the next step involved collaboration with residents and their families to develop consensus about whether to proceed with a PC consult and establish the plan of care. This process was referred to by participants as “getting everyone on the same page.” This process exhibited notable variability across different healthcare facilities, with a range of staff members, including social workers, nursing directors, unit managers, and staff nurses, taking on the responsibility of facilitating these discussions. Additionally, some NH nurse practitioners mentioned that they often played an active role in these conversations, offering recommendations for PC referrals and ensuring that questions were addressed, anticipatory guidance provided, and the referral aligned with the residents’ and families’ goals of care.

“I would say it is probably 50–50 between the nurse practitioner and nursing management. They would reach out to family and get the process started, explain what’s going on [recommendations for PC], and get their input and approval to proceed further.” (Participant 06, NH Administrator)

It was common practice that providers were approached by NH staff to assess eligibility before any discussions about referral took place with residents and their families. However, in some facilities this order was reversed. Some facilities, upon identifying residents who might benefit from PC, opted to initiate conversations about care goals and PC referral with residents and family members as the next logical step. This variation seemed to be influenced by provider workflow preferences, comfort levels of staff in engaging in these sensitive conversations, and depth of the relationships that staff had established with residents and their families.

Barriers.

Lack of education and prevalent misconceptions surrounding PC emerged as significant barriers in NHs. Most participants acknowledged the persistent challenge of distinguishing between PC and end-of-life care, even among healthcare professionals. The common misconception that PC exclusively denotes end-of-life was thought to impede broader understanding of PC, which is to enhance comfort and quality of life for individuals facing serious illness, irrespective of their life expectancy.

“There needs to be more education. A lot of people think PC means end of life, but it doesn’t. It means that we want to do more to help them be comfortable. I think education on that, is a big, big thing, because not everybody is educated as to what that means.” (Participant 1, NH Registered Nurse)

Another barrier reported by participants was that of residents transitioning from hospital to NH with unrealistically optimistic goals, as communicated by the hospital, creating a stark contrast with the PC needs identified by NH staff. Coping with the unexpected shift in expectations was reported as challenging and emotionally distressing for families. This incongruity in messaging was reported as leading to delayed initiation of appropriate PC interventions and hindering establishment of realistic care plans.

“A lot of times the hospital discharges the resident to [NH] rehab and you realize this resident is not rehabable. But they don’t want to hear palliative or hospice right away because that’s not what they were told at the hospital… I think there’s a huge barrier as far as the hospital communicating one thing and then providers in the nursing home communicating something different.” (Participant 7, NH Nurse Practitioner)

Solutions.

The knowledge gap identified by participants was highlighted as a critical area for targeted educational initiatives to ensure that both staff and families possess accurate understanding of PC principles, fostering a more informed and receptive approach to its implementation. Notably, one participant suggested the adoption of a campaign to mitigate the stigma associated with palliative and hospice care. Drawing parallels to successful efforts to destigmatize mental health, this participant emphasized the importance of altering public perceptions to foster greater understanding and acceptance of PC.

In addition, anticipatory guidance emerged as a crucial element in fostering acceptance of PC among NH residents and their families. One participant described a hospital-based program led by nurse practitioners, offering guidance before individuals transition from hospitals to NHs. Other participants stressed the role of anticipatory guidance in helping families understand the inevitable trajectory of decline, advocating for a more “graceful” approach. Notably, the importance of anticipatory guidance, coupled with early engagement with family and involving residents while they still retain decision-making capacity was emphasized, particularly for residents living with dementia. Participants emphasized that placing a priority on anticipatory guidance within NHs has the potential to establish a shared understanding and contribute to consensus building around PC.

“We see the trajectory so many times and we know we can’t prevent the decline, but we can walk the family through decline a little more gracefully and anticipating the needs that the family and the resident is going to have along the way.” (Participant 2, NH Nurse Practitioner)

“With any dementia diagnosis, anticipatory guidance and planning is needed. There’s a lot to talk through, engaging with caregivers and trying to involve persons living with dementia early in their illness trajectory while they might still have decision making capacity. I think it also depends on the stage of dementia and what is expected from the nursing home stay.” (Participant 17, PC Nurse Practitioner)

Consultation.

The consultation phase involves the formal initiation of the PC referral process, including the placement of orders and obtaining the necessary consultation and services. Typically, the responsibility for coordinating the initiation of PC, falls to the nursing staff or the social worker. However, it is worth noting that some nurse practitioner participants mentioned that they took on this role to ensure that the process proceeded smoothly and promptly.

“Once everybody agrees, resident, family, and all staff, because I want to make sure everybody, including nursing staff, is seeing the same thing I’m seeing. And if everybody’s like, yep, we all think that’s the best thing, then we make the referral.” [Participant 15, NH Nurse Practitioner]

Barriers.

Participants revealed barriers to accessing PC consultations, emphasizing geographical, transportation, and workforce-related challenges. In rural areas, geographical barriers were mentioned as contributing to delayed access to PC services. One participant highlighted the extended wait times for a PC nurse practitioner to visit patients in a rurally located facility because she is the sole provider in their region. A nurse practitioner in another NH emphasized the scarcity of specialty PC providers capable of receiving referrals both within the facility and on an outpatient basis, underscoring workforce-related issues. For NHs without PC specialists willing to travel to the NH and see patients, transportation was mentioned as a particular challenge, particularly for residents with dementia, reinforcing the need for more accessible PC services within the NH setting.

“The problem that I see sometimes is that she is the only one in this area that does provide that PC service. And we’re kind of in a rural area, so sometimes it does take a while to get her in here, sometimes it might take two weeks.” (Participant 6, NH Administrator)

“Most of my residents are unable to leave the facility easily so, we will refer to palliative that’s available at the facility without needing transportation. Transportation is huge for these residents. We avoid sending residents with dementia out anywhere for appointments because it can be very traumatic for them.” (Participant 14, NH Nurse Practitioner)

Solutions.

Participants proposed a hierarchical consultation framework, beginning with primary PC services delivered by on-site primary care providers. This was followed by on-site specialty PC, which included telehealth, with referral to off-site consultations only in special cases. Both NH providers and specialty PC providers emphasized the expertise of NH providers in caring for seriously ill older adults. Several of the NH providers interviewed indicated that they were providing primary PC services in lieu of outsourcing such care. Participants highlighted that, given workforce, policy, and financial constraints, NH providers are well-suited to offer primary PC services, including advance care planning, anticipatory guidance and symptom management. Additionally, participants suggested that, beyond primary PC, the optimal solution would involve PC specialists directly seeing patients in the NH, mitigating transportation-related challenges.

“I think I could make an argument that everyone that’s long-term care would benefit from PC involvement. But we don’t have the workforce and probably the policy, and financial reimbursement. So, I think primary PC is a solution, and we could emphasize basic advanced care planning and basic pain and symptom management and focus on resident and family centered care as what nursing home staff should be able to do.” (Participant 17, PC Nurse Practitioner)

Discussion

Nursing home staff and providers play a crucial role in referring seriously ill residents for specialist PC. However, a comprehensive exploration of their perspectives on identification and referral processes in NHs has been lacking. Our study fills this gap, shedding light on the multistep process of PC referrals in NHs. Through in-depth interviews, we identified four distinct stages in the referral process: resident identification, eligibility assessment, consensus-building, and consultation. Results call for increased PC training for all NH staff, standardized methods for timely identification of residents with unmet PC needs, comprehensive payment models to support residents living with serious illness, and models of care that increase PC access for NH residents.

To enhance the delivery of PC in NHs, staff education and the implementation of standardized processes are vital. Several studies underscore the significant impact of staff knowledge on the quality of care provided. For example, Miller et al. (2015) found that Directors of Nursing (DONs) with higher levels of PC knowledge and practice were associated with better management of chronic symptoms and fewer unnecessary interventions in residents nearing the end of life. Similarly, Smets et al. (2018) reported a general deficiency in staff knowledge about common PC issues, indicating a broad need for enhanced educational programs. These findings highlight the importance of targeted training programs, as NH staff often fail to appreciate their crucial role in managing residents’ complex care needs.

Integrating PC screening tools with clearly defined criteria into existing workflows can also address this knowledge gap, fostering a more proactive and informed PC referral process. This structured approach may reduce reliance on subjective judgment, ensuring that staff knowledge aligns with eligibility criteria for PC. By embedding structured screening tools and documentation into routine workflows such as MDS assessments, the challenges of staff turnover and ongoing need for retraining—which significantly hinder care quality improvement—could be mitigated. Moreover, as NH staff consistently utilize these tools in resident care, they may become more adept at identifying eligible residents and enhance their communication with healthcare providers and families, advocating more effectively for residents’ needs. Although residents and families may choose to decline PC, NH staff and providers can play a key role in ensuring that timely PC is offered and provide important education about PC, allowing residents and families to make informed decisions regarding their care.

In addition, findings illuminate significant misperceptions in utilizing PC for post-acute SNF patients. The common confusion between PC and hospice care, coupled with insurance restrictions, often results in SNF residents being overlooked for PC despite its potential benefits. This is exacerbated by financial disincentives for both facilities and families, rootedin Medicare’s reimbursement structures, which favor short-stay SNF care over transitioning to hospice care due to the coverage of room and board costs (Carlson et al., 2011). Such economic considerations not only influence facility preferences but also place families in a difficult position, having to choose between continued SNF care and the out-of-pocket costs associated with hospice care (Carpenter, 2022).

The hospice benefit under Medicare Part A includes comprehensive end-of-life care, but it requires patients to forego curative treatments and focuses solely on comfort care for those with a life expectancy of six months or less. Conversely, PC can be provided at any stage of a serious illness and can be received alongside curative treatments.

As pointed out by some participants, Medicare Part B covers PC consultations and treatments, allowing SNF residents to benefit from these services without losing their Medicare Part A SNF benefits. This arrangement enables residents to benefit from PC services without compromising their SNF benefits provided under Medicare Part A. This solution assists SNF residents with serious illnesses to access the comprehensive care they need without the risk of insurance discontinuation. Furthermore, initiating PC, which allows for ongoing treatment, could serve as a more appropriate care model for many residents, potentially enhancing quality of life and reducing the need for hospital readmissions (Miller et al., 2016). Widespread systemic reforms aimed at enhancing the integration of PC within post-acute SNF environments, tackling both the obstacles imposed by current policies and addressing the essential care requirements of this vulnerable group are greatly needed (Carpenter et al., 2017).

There is a pressing need for care models that enhance the provision of high-quality PC directly within NHs, eliminating the necessity for residents to seek services externally. Nurse practitioners, along with physicians and physician assistants, with their expertise in geriatric care, are well-positioned to lead this initiative, as they can deliver primary PC services on-site, supplemented by specialists consultations via telehealth or in-person as necessary. This model which avoids outpatient consultations except in special cases ensures that PC is both accessible and tailored to the residents’ needs, effectively addressing barriers such as geographical location, transportation, and workforce challenges by integrating PC services within the NH environment. Recent literature shows that such integrated PC models are well received by residents, their families, and beneficial to NH staff (Carpenter et al., 2024). By making PC a fundamental aspect of care in NHs, we can ensure that all residents have access to the comprehensive support they require (Ersek et al., 2022).

However, while NH providers are adept at managing the comprehensive health needs of older adults, including chronic conditions and general wellness, their role in PC typically focuses on comfort and symptom management. To effectively provide this integrated care, NH providers benefit from enhanced training in specific palliative care skills such as advanced communication, symptom management, and psychosocial care (Carpenter & Ersek, 2021). Such training would ensure that primary PC is not just a component of good geriatric care but a distinct, crucial element that aligns closely with the residents’ values and preferences, improving the quality of life for older adults navigating the complexities of serious illnesses in NHs.

Ultimately, the success of such models depends on the NH staff’s ability to promptly recognize and communicate new or ongoing resident needs to providers. The full potential of these PC models remains unrealized without the accurate and timely identification of residents who require PC and improved communication strategies between staff and providers. Thus, there is a pressing need for research focused on developing and implementing standardized methods for timely identification of unmet PC needs and enhancing communication channels between NH staff, primary care providers, and palliative care specialists, ensuring a seamless integration of PC services within NHs.

Limitations

The study sample was limited to individuals who responded to the list servs and recruitment advertisements, which may suggest a greater willingness to engage in discussions on this issue. Additionally, it is important to note that the participants were drawn from just six states and represent majority of providers who identify as White and female. Future studies need to include a more diverse and representative sample to enhance the robustness of the results and their application to research and practice. Moreover, integrating quantitative methodologies could further illuminate the impact of identified barriers and solutions on PC delivery, providing a more comprehensive understanding of the factors influencing utilization in NHs.

Conclusion

This study emphasizes the need for strategies to enhance PC referrals in NHs, highlighting staff education, standardized referral protocols, and integrating PC into models of care. There is a need for comprehensive training to improve staff capability in PC identification and referral, alongside the implementation of standardized referral criteria to ensure equitable access. Importantly, there is a specific need for enhanced training for primary care providers in NHs to bolster their skills in delivering primary palliative care. Furthermore, incorporating PC services directly within NHs addresses access barriers and calls for collaborative efforts among administrators, healthcare providers, and policymakers to reform constraining policies. These steps would assist in standardizing PC as a crucial element of high-quality NH care, thus improving the quality of life for residents with serious illnesses.

A poster abstract of this manuscript was presented at the 2024 Annual Assembly of Hospice and Palliative Care.

What this paper adds.

• The palliative care referral process in nursing homes comprises four stages: resident identification, eligibility assessment, consensus-building, and consultation.

• Barriers to palliative care referral were identified as lack of referral standards, absence of screening process, insufficient staff training, financial disincentives, and logistical challenges.

• Recommended solutions include integrating screening for unmet palliative care needs into routine workflows, expanding the use of palliative care for residents utilizing post-acute skilled nursing facility care, and enhancing training and skills of existing primary care providers in nursing homes to deliver palliative care directly within the facility.