Interdisciplinary Training to Enhance Home Health Clinician Knowledge of Palliative Care: Findings from the PIVOT Pilot Study

Abstract

Background:

Older adults receiving home health care (HHC) frequently experience serious illness, yet palliative care (PC) is rarely integrated into HHC practice.

Objective:

To develop and evaluate an interdisciplinary program to support a PalliatIVe hOme healTh (PIVOT) model to build HHC clinicians’ knowledge and confidence in addressing PC needs.

Methods:

PIVOT included home health clinicians who completed 4 hours of online discipline-specific learning and an in-person session with case-based didactics, facilitated discussion, and reflective exercises. Pre- and post-training surveys assessed knowledge, confidence, and comfort across PC domains.

Results:

Participants reported improvements in confidence assessing and managing symptoms, knowledge of advance directives, and comfort updating directives. The largest increase was in understanding what specialty PC provides. All participants rated the training as “very helpful” and indicated intention to apply skills in practice.

Conclusions:

This interdisciplinary pilot training demonstrated feasibility and early signals of improved PC knowledge and readiness among HHC clinicians to implement core PC practices.

Introduction

As the U.S. population ages, a growing number of older adults are living with serious and complex medical conditions that impact quality of life.(1, 2) Home health care (HHC) is a key care setting for supporting this population at home.(3) However, despite increasing demand and complexity of care in HHC, many HHC patients experience unmet palliative care (PC) needs, leading to increased symptom burden, unnecessary hospitalizations, and diminished quality of life.(4)

A substantial proportion of older adults receiving HHC services have unmet PC needs.(5) In one study, approximately 28.8% of community-dwelling older adults were found to have unmet PC needs, with lower education and living alone being significant predictors.(6) These unmet needs often encompass pain management, psychological support, and assistance with advance care planning.

Effective PC relies on an interdisciplinary approach, integrating the expertise of various healthcare professionals to address the multifaceted needs of patients. Physical therapists (PTs) and occupational therapists (OTs), play crucial roles in enhancing patients’ functional abilities, promoting independence, and improving quality of life. Despite their potential, PTs and OTs are often excluded from PC delivery in HHC, partly due to limited training and unclear roles.(7, 8)

A significant barrier to integrating PC into HHC is the limited PC education and training. Many HHC professionals, including nurses, PTs, and OTs, report low confidence in managing PC needs, particularly concerning symptom management, communication about end-of-life issues, and advance care planning.(9) This educational gap underscores the necessity for targeted training programs that equip HHC clinicians with the knowledge and skills required to deliver comprehensive PC.

The PIVOT Model: Addressing the Gap

In response to these challenges, we developed the PalliatIVe hOme healTh (PIVOT) model, an interdisciplinary training program designed to enhance the PC competencies of HHC clinicians. This was developed using insights from inpatient, primary care, and HHC providers who identified opportunities to integrate PC into home-based care delivery.(10) This pilot study evaluated the feasibility and outcomes of the PIVOT training, focusing on improvements in clinicians’ knowledge, confidence, and comfort in delivering PC within the home setting.

Methods

Design and Participants

Two Denver-area HHC agencies were selected a priori based on pre-existing relationships with the investigator team and/or based on active referral pathways between the main referring hospital and the agencies. Agency leadership introduced the training opportunity via internal staff communications. Eligible participants were licensed nurses (RNs), PTs, OTs, or social workers delivering HHC who were able to complete online modules as well as attend in-person training. Training time was reimbursed at $50/hour. Our target sample included six trainees across two agencies to ensure role representation and to assess pilot feasibility.

This pilot study utilized a pre-post design to evaluate the feasibility and early outcomes of the PIVOT training program among interdisciplinary home health clinicians. The PIVOT training was implemented over a four-week period and included two components: a self-paced online curriculum and a half-day in-person interactive session. The training aimed to enhance knowledge and confidence in core PC domains, including symptom management, advance care planning (ACP), caregiver support, and interdisciplinary collaboration.

The online modules were completed independently over three weeks. Nurses completed the ELNEC Core Curriculum(11), which covered foundational principles of palliative care. PTs and OTs completed custom training materials (Supplementary Data 1), including a novel course that was developed titled ‘Palliative Therapy in the Home: Strategies for Success.’(12) These modules addressed the role of rehabilitation clinicians in supporting patients with progressive illness and functional decline. The online training was estimated to take approximately 4 hours to complete.

The in-person session was held after completing the online modules in week four and consisted of interactive didactics, case-based role play, and group discussions. Content focused on identifying patients with palliative needs, conducting symptom assessments, initiating ACP conversations, and documenting and communicating care plans using a standardized PIVOT Care Plan Summary. Training also addressed local tools such as the state’s version of the POLST form and Medical Durable Power of Attorney (MDPOA). The in-person session took approximately 4 hours to complete.

The PIVOT study was approved by the Colorado Multiple Institutional Review Board. Participants provided electronic consent via a secure, web-based Research Electronic Data Capture (REDCap) tool hosted at The University of Colorado Denver (NIH/NCRR Colorado CTSI Grant Number UL1 RR025780).(13, 14) All data was collected and managed in REDCap.

Evaluation

A 12-item pre-training survey was electronically administered via a REDCap Survey immediately before the online training began (Supplementary Data 2). The post-training survey, which included matched items plus open-ended questions, was administered at the end of the in-person session. Surveys measured changes in knowledge, confidence, and comfort on a 5-point Likert scale across the following PC domains:

• Symptom assessment and management;

• Advance care planning and directive knowledge;

• Caregiver burden recognition and referral;

• Adjusting care plans to address PC needs; and

• Understanding of specialty PC.

Participants also reported training satisfaction and takeaways.

Results

Three home health clinicians – one RN, one PT, and one OT – participated in the PIVOT pilot training and both pre- and post-training surveys. A fourth clinician (an OT) completed the pre-survey but was unable to attend the in-person training and was excluded from post-training analysis. All trainees were recruited from one HHC agency. The second planned agency withdrew before launch because of COVID-19 related staffing shortages.

Quantitative analysis of survey responses revealed promising gains in several domains. Confidence in assessing symptoms such as pain and shortness of breath increased from a pre-training mean of 4.3 (Fairly confident) to 5 (Very confident). Confidence in managing symptoms rose from 3.7 to 4.3. Knowledge about advance directive forms improved from 3.7 to 4.0, and comfort identifying the need to update advance directives increased from 3.7 to 4.3.

Participants reported increased confidence in adjusting HHC plans to align with palliative needs (4.0 to 4.3), and the largest gain was observed in knowledge of what specialty PC provides (2.0 to 4.3). Qualitative responses highlighted improvements in understanding when and how to initiate referrals, appreciation for structured care pathways, and greater clarity on interdisciplinary roles. One participant noted that the “[case based] flow charts of what to do” were helpful for clarifying next, underscoring the value of decision-making tools. Others highlighted expanded knowledge of caregiver support strategies, as well as tools such as the Edmonton Symptom Assessment System (15) and Zarit Burden Interview.(16)

All participants rated the training delivery method as ‘Very good’ and found the combination of online and in-person formats to be highly satisfactory. They unanimously rated the content as ‘Very helpful’ in growing PC skills. Two of three indicated they were ‘Very likely’ to implement the training in their practice, and the third was ‘Somewhat likely.’ Participants also expressed interest in further training on caregiver needs, PC referral options, and practical case scenarios. One participant requested additional examples on how to approach patients who may be reluctant to engage in PC discussions.

Satisfaction with the online training materials—including the ELNEC modules and PT/OT-focused content—was high. All participants indicated they would recommend the training to peers. No substantive suggestions for curriculum changes were offered in open-ended survey responses. Inferential statistical analyses were not performed due to the small sample size.

Discussion

This pilot offers proof of concept that interdisciplinary training to enhance PC competencies in HHC is feasible and satisfactory. Despite the small size of this pilot, findings suggest home health clinician interest in this type of training, and promising gains in knowledge, confidence, and comfort with core PC domains such as symptom management, advance care planning, and caregiver support.

The largest improvements were observed in participants’ knowledge of specialty PC services and confidence in adjusting home health care plans to meet patients’ needs. This is particularly relevant and clinically important for these home health teams, as they are often the first to detect worsening symptoms, caregiver strain, or the need for advance care planning, but may lack the structured training and tools to act.

Several components of the PIVOT training may have contributed to its preliminary signals of success. The longitudinal online curriculum provided foundational knowledge, while the in-person training allowed for role-based discussion, interactive case-based learning, and facilitated interprofessional exchange. Importantly, the curriculum was tailored for each discipline and included local resources and documentation practices, such as state-specific advance directive forms.

Our findings are consistent with prior work emphasizing the importance of targeted, role-specific training for non-physician providers in PC delivery.(17–20) Moreover, the integration of interdisciplinary learning and implementation support reflects a growing recognition that scalable models of home-based palliative care must engage the full care team.(21–24)

This study also highlights areas for improvement. Participants expressed interest in deeper content on caregiver burden and clearer case-based narratives on engaging resistant patients. While no curriculum changes were suggested formally, future iterations may benefit from including more dynamic learning components and case simulations. A larger-scale trial is needed to evaluate the effectiveness of the training on patient and caregiver outcomes, clinician behavior change, and care utilization metrics.

Limitations of this study include the small sample size, absence of a control group, and short follow-up period. Results may not generalize to other home health agencies or geographic regions. However, by documenting the training design, content, and implementation logistics, this report aims to support replication and adaptation, and further testing in other settings.

Conclusion

This pilot study provides early proof of concept that a structured, interdisciplinary training program is feasible and has potential to enhance home health clinicians’ confidence and knowledge in delivering palliative care. The PIVOT training model was well received and showed measurable improvements in critical PC domains such as symptom assessment, advance care planning, and caregiver support. While further evaluation is needed, this report provides a replicable model for home health agencies seeking to integrate palliative principles into routine care.