The aging population, along with advances in medical care, means people are living longer with chronic conditions. This creates a growing need for the healthcare workforce to have expertise in serious illness care, including clinical expertise in complex care and in conducting goals-of-care conversations. Since people with serious illness are cared for at multiple sites, such skills are needed across the continuum of care. This blog piece calls for a multidisciplinary approach to provide more comprehensive and effective conversations with patients, pointing out that team-based models of care are becoming more prevalent in value-based medicine. The piece looks at the Conversation Nurse Model developed by Care New England in Rhode Island. The program trains nurses in conversational skills to talk with patients about serious illness and their goals for their care. The model has been used to increase the workforce trained in serious illness care and have shown the following outcomes:
- Increased volume of palliative care consults in inpatient settings;
- Increased documentation of advance directives in the home care agency population;
- Decreased readmissions and increased hospice consults in skilled nursing facilities; and
- Broad training of interprofessional teams.
The model, which started in the inpatient setting and expanded into the community, has since been extended to Care New England's home care agency, with visiting nurses trained in the basics of complex conversations and engaging with new patients to help them identify their health care proxies and goals of care.