Eliciting and Honoring What Matters Most in the Nursing Home: A Primary Palliative Care Approach to Improving End-of-Life Outcomes

BACKGROUND: Nursing homes provide a substantial proportion of end-of-life care but often face fragmented communication, inconsistent care planning, and limited access to specialty palliative care. These gaps highlight the need for scalable primary palliative care models. METHODS: The authors conducted a descriptive quality improvement project across 28 community nursing homes in northern California. A multicomponent primary palliative care model included clinician education, nurse care navigation, and system-level supports. Outcomes included documented goals-of-care conversations, hospice length of stay among decedents, and inpatient days per member per month, analyzed using statistical process control methods. Implementation was supported through standardized tools and Plan-Do-Study-Act cycles. RESULTS: As a pre-to-postevaluation without a comparison group, findings may reflect changes over time independent of the intervention. Documented goals-of-care conversations increased from 12.0 to 30.0 per month from 2022 to 2023. Median hospice length of stay increased from 10.1 days (N = 9) to 24.6 days (N = 24), although interpretation was limited by the small sample sizes. Inpatient utilization decreased from 0.70 to 0.42 days per member per month, representing 673 fewer inpatient days despite an increased long-term care census. CONCLUSION: Implementation of a multicomponent primary palliative care model coincided with improvements in care patterns over time. However, the study design did not allow attribution of these changes to the intervention itself, and observed improvements may reflect underlying temporal trends. Future studies should incorporate patient and family-reported outcomes and use more rigorous evaluation designs to better isolate intervention effects. Given workforce shortages in specialty palliative care, this model warrants further study as a potentially scalable approach to improving palliative care delivery in nursing homes.