Advance Directives: Improving Patient Care at End-of-Life
By Rhea Go-Coloma, LMSW
Mary, 89, who has a history of heart failure and spinal stenosis, lives at home with her elderly husband. Over the past few months, she’s been admitted twice to the hospital with symptoms of heart failure. Her Medicare Advantage plan used a predictive algorithm to identify Mary as a candidate for home-based palliative care. When seen at home on the first visit, the palliative nurse discussed with her specific goals of care.