Community palliative care initiatives to reduce end-of-life hospital utilization and in-hospital deaths: a population-based observational study evaluating two home care interventions

Context — The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home.

Objectives — To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients.

Methods — This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regression was used to evaluate outcomes according to patients' receipt of intervention(s).

Results — The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (p < 0.0001). Compared to patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk=2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalizations or emergency department visits in the six months prior to death.

Conclusion — Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end-of-life. This association was stronger when these interventions were used together.