Date of Award

Fall 2018

Project Type

Clinical Doctorate

College or School




Program or Major

Doctorate of Nursing Practice

Degree Name


First Advisor

Raelene Shippee-Rice

Second Advisor

Joanne Samuels



There is a rising number of patients with chronic health conditions concurrent with an increasing number of hospital readmissions within 30 days and emergency department visits. Predominantly based in acute care facilities, palliative care services have been effective in improving the quality of life in patients with chronic health conditions. However, the largest population that could benefit from palliative care services is community based in the home setting.


The purpose of this project was the implement and evaluate follow-up telephone calls made in addition to visiting nursing (VNA) services to detect in early decline in patients who have received in-patient palliative care services compared to a 12-month retrospective analysis of a mirror population.


Five telephone calls were made over a 30-day time frame using the palliative performance scale as the method of measurement to augment VNA services with an additional layer of monitoring for early detection of decline. A 12-month retrospective analysis of a mirror population was performed for baseline comparison. ER visits, 30-day hospital readmissions, hospice admissions, and hospice lengths of stay were the methods of outcome.


One participant was included in the implement telephone calls for inconclusive results. While, the retrospective data populations of 45 patients accounted for 141 hospitalizations, 71 30-day readmissions, 65 ER visits, 15 hospice admissions, and an average hospice length of stay of 58.3 days.


Patients who receive palliative care services in the hospital would benefit from the extension of in-person palliative care into the home setting for better symptom management and advanced care planning to improve quality of care and outcomes.