Improving the Inpatient/Home-Based Communication in a Palliative Care Continuum Through Use of a Smart Phrase

From the 2022 HVPA National Conference

Stephanie Downs CRNP, MSN (Lehigh Valley Health Network), Imran Shariff MD, Kimberly Spering CRNP, Jennifer Cooper BSN, Kathryn Zaffiri MPH


– Improve communication between inpatient and home-based palliative care providers

– Highlight the importance of home-based palliative care, through identification of potential barriers to specific patient care needs

– Improve continuity of care and patient outcomes, both in the home and hospital settings


Palliative Care is a young field, with multiple tenets that are often not well-understood by the greater medical team and public. Many hospitals offer inpatient palliative consultations, outpatient/clinic consultations, and occasionally, home-based palliative care. Very few studies have been done to evaluate collaboration between inpatient and home-based palliative care teams. Breakdown in communication among providers can lead to poor continuity of care, potential for more frequent readmissions, frustration among patient and family, potential mistrust of the healthcare system, and potential for lost follow ups.


We proposed a method to initiate discussions between inpatient and home-based palliative care providers, with a goal of facilitating communication, understanding potential barriers in communication with patients and families, and to assist the entire team with providing better patient and family support in the hospital and home settings. Using our electronic medical record, a “smart phrase” was created that captured discussions with the team members, changes in goals of care, and disposition upon hospital discharge. This smart phrase allowed providers on both the inpatient and home-based team to easily communicate and access details vital to their patient’s care and the care continuum.


From September 2021 to March 2022, there were 48 home-based palliative care patients admitted. During this period, palliative care involvement led to a change in care in nearly 80% of patients. 39% of patients transitioned to hospice, 21% had a change in code status, 14% required a medication change or palliative care provided cultural support, and 11% had a change in disposition from home to a skilled nursing facility. Time to inpatient consult decreased from 4.7 days to 3.4 days. A survey was used to gather feedback from colleagues who used the smart phrase. Respondents included both inpatient and the home-based clinicians (N=12). When asked if the smart phrase was valuable to patient care, 83.3% responded ‘Yes’. 91.7% reported the smart phrase improved patient and/or family interactions. All participants said the project helped to create a better sense of team involvement when taking care of patients. Qualitative feedback was obtained. Notable quotes include: “The [smart] phrase is very helpful in reminding me to connect with the home-based NP. It helps with collaboration.” Some feedback showed there are still opportunities for improving upon this project: “Most of the time when I communicated with [home-based] team, I didn’t get any information other than which was already in the chart…”.


This project offered the opportunity to explore potential barriers to patient care and team communication. It confirmed the importance of collaboration between palliative care providers. This communication ultimately benefits patients and their families, through improvement in care coordination and continuity.

Clinical Implications

This project demonstrated a simple and effective method of communication that can be modified and applied to multiple sub-specialties and general practitioners, as continuity of care could improve patient outcomes.

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