Background: Patients living in rural areas experience a variety of unmet needs that result in healthcare disparities. The triple threat of rural geography, racial inequities, and older age hinders access to high-quality palliative care (PC) for a significant proportion of Americans. Rural patients with life-limiting illness are at risk of not receiving appropriate palliative care due to a limited specialty workforce, long distances to treatment centers, and limited PC clinical expertise. Although culture strongly influences people's response to diagnosis, illness, and treatment preferences, culturally based care models are not currently available for most seriously ill rural patients and their family caregivers. The purpose of this randomized clinical trial (RCT) is to compare a culturally based tele-consult program (that was developed by and for the rural southern African American (AA) and White (W) population) to usual hospital care to determine the impact on symptom burden (primary outcome) and patient and care partner quality of life (QOL), care partner burden, and resource use postdischarge (secondary outcomes) in hospitalized AA and White older adults with a life-limiting illness. Methods: Community Tele-pal is a three-site RCT that will test the efficacy of a community-developed, culturally based PC teleconsult program for hospitalized rural AA and W older adults with life-limiting illnesses (n = 352) and a care partner. Half of the participants (n = 176) and a care partner (n = 176) will be randomized to receive the culturally based palliative care consult. The other half of the patient participants (n = 176) and care partners (n = 176) will receive usual hospital care appropriate to their illness. Discussion: This is the first community-developed, culturally based PC tele-consult program for rural southern AA and W populations. If effective, the tele-consult palliative program and methods will serve as a model for future culturally based PC programs that can reduce patients' symptoms and care partner burden.

Chief complaint: Right hand and arm rash. History of present illness:A 31-year-old. right-handdominant, ivhite male office worker presents for evaluation of multiple clusters of erythematous papules on the dorsum of his right hand. H e states that the lesions began as an isolated nodule three months prior to this evaluation. He did not seek medical attention initially. and treated the lesions with soap. water. and cortisone cream. However, when the nodules increased in size and additional nodules appeared. the patient sought the advice of his family physician. who placed the patient on cefadroxil. After completion of a two-week course of treatment. the lesions increased in number and gradually spread proximally to his axilla.Constitutional symptoms, including fevers, chills, night sweats. productive or nonproductive cough, fatigue. and weight loss, are absent. The patient denies risk factors for immunosuppressive disorders. The patient takes no other medication and has no history of drug allergies. Further discussion reveals that his hobbies include keeping and caring for three tanks of tropical fish. Physical examination:The patient is in n o acute distress. His vital signs are normal. Examination of the dorsum of the right hand reveals multiple clusters of nontender. indurated papules on erythematous bases (Fig. 1). N o swelling. warmth. or drainage is noted. The right volar I FlGURE I . The patient's hand on ED presentation forearm contains multiple. discrete. erythematous. nontender, nonfluctuant. subcutaneous nodules approximately 1 cm in diameter. Several erythematous, nontender, fluctuant. subcutaneous nodules larger than those on the forearm are seen on the proximal aspect of the right arm. No axillary adenopathy is noted, although superficial phlebitis with palpable cords cover5 the entire arm.Laboratory and additional tests: Radiographs of the right upper extremity reveal only soft-tissue swelling. A procedure is performed and the patient is scheduled for follow-up.