Medicalisation of palliative care needs rounds

  • Telehealth meeting
    Dr Susan Haynes leads a 'needs round' using telehealth technology
By
Susan Haynes, Paul Tait and Lisa Macdonald
South Australia Health and Flinders University
Issue
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Older Australians admitted to residential aged care homes (RACHs) are medically complex. Not only do they experience multimorbidity and polypharmacy, but they are often living with a life-limiting illness, such as dementia. Although general practitioners (GPs) are well positioned to provide such care, they face several challenges and barriers in doing so. Indeed, working in regional settings has compounding challenges, including limited access to specialists, inadequate remuneration, and fewer training opportunities.

With funding from the South Australian and Commonwealth Governments under the Comprehensive Palliative Care in Aged Care (CPCiAC) Project, we set out to address these challenges observed by GPs working with RACHs throughout regional South Australia. Our multi-component intervention centred around an adapted Needs Round (NR) model to meet RACH residents' complex palliative care (PC) and medical needs. While the Calvary NRs traditionally involve specialist nurses from specialist palliative care services (SPCSs) and RACHs regularly discussing and reviewing six to eight residents at a higher risk of dying, we have built on this concept by including the GP and palliative medicine specialist in our regional model. Acknowledging gaps in the MBS for such clinical discussions, we funded the GPs involvement.

To evaluate the medical NR model, we used the ELDAC after-death audit to review resident and family outcomes upon their death. The audit measures various aspects of PC provided in the RACH, including advance care planning, family discussions around goals of care, and bereavement follow-up. We have demonstrated meaningful results for residents and their families involved with RACHs participating in our medicalised NR model, including:

  • Data shows that staff at the project sites were more likely to document where the residents wished to be cared for should they deteriorate during the project than before (56% vs 85%).
  • Palliative Care Family Meetings or Case Conferences increased from 37% to 65%.
  • Team case conferences discussing the residents' palliative care needs increased from 12% to 41%.
  • Data shows that staff at the project sites were more likely to commence residents on an End-of-Life Care Pathway or Care Plan during the project than before (69% vs 49%).
  • Almost a doubling of resident families assessed for bereavement risk from 22% to 43%
  • Aged care staff referred families for bereavement support four times as many times in the active phase of the project, with the proportion increasing from 3% to 12%.

The in-depth discussions at the medical-led NRs underpin these results. With medical, nursing and sometimes pharmacy at the table, the multidisciplinary team identifies the right individual to work with the GP to address medically complex residents. In doing so, we have improved access to specialist advice and provided remuneration and training opportunities for GPs providing end of life care in RACHs.

Given that regional GPs also support people living in their home dwellings and, in some cases, acute regional hospitals, we expect their involvement in NRs will have far-reaching impacts that we have been unable to measure. Indeed, we hope that through our connection in facilitating medical-led NRs in RACHs, we are also building medical capacity within regional communities.

We propose that regionally based organisations think outside the square, building on the existing evidence base to overcome the challenges in providing medical support to RACH residents at the end of life.

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