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J Palliat Med. 2008 Mar;11(2):217-25. doi: 10.1089/jpm.2007.0147.

Improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation.

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Department of Medicine, University of Colorado, Aurora, Colorado, USA.



The objectives were (1) to describe the Making Advance Planning a Priority (MAPP) program, a program designed to identify nursing home (NH) residents at high risk of death and (2) to evaluate end-of-life care outcomes for NH residents at high risk of death.


PROGRAM DESCRIPTION and evaluation using a retrospective chart review before and after implementation of the MAPP program.


NH residents who died 1 year before program implementation compared to NH residents who died 1 year after program implementation (n = 72).


The MAPP program was designed to: (1) identify residents at high risk of death, (2) inform the attending physician of the residents' mortality risk, (3) obtain palliative care or, if the prognosis was 6 months of less, a hospice consultation, and (4) improve advance care planning documentation.


Site of death (hospital versus nursing home), presence of an advance directive, presence of an order for cardiopulmonary resuscitation, proportion of NH residents with palliative care and/or hospice consultation prior to death, length of palliative care and/or hospice services before death. Following implementation of the MAPP program, we hypothesized that there would be a reduction in hospitalizations, an increase in hospice/palliative care referrals, an increase hospice/palliative care length of service, an increase the utilization of advance directives, but no difference in days in the hospital before death.


Following implementation of the MAPP program intervention, residents were less likely to die in the hospital (48.2% preintervention versus 8.9% postintervention, p < 0.0001). Every resident who died after implementation of the MAPP program had an advanced directive (p = 0.03). Residents were more also more likely to get palliative care referrals (7.4% preintervention versus 31.1% postintervention, p = 0.02).


An intervention designed to address the end-of-life needs of NH residents at high risk of death improves end-of-life outcomes with a reduction in terminal hospitalizations, an increase in palliative care referrals and improvement of advance directive completion.

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