Improving capacity for provision of community end-of-life care presented by Professor Liz Reymond
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Conference presentation at the Primary Health Research conference in Canberra (ACT) on the 8 and 9 June 2016.
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Improving capacity for provision of community end-of-life care presented by Professor Liz Reymond
- 1. PHC: Innovation and best practice Improving capacity for provision of community end-of-life care Prof Liz Reymond MBBS (Hons) RACGP FAChPM PhD Australian and New Zealand Society of Palliative Medicine Inc
- 2. Presentation overview • Background to Decision Assist • Development of GP Educational Strategy within Decision Assist – Palliative Care Framework of care based on prognostication • Findings to date © Not to be used or modified without the permission of ANZSPM
- 3. Background • Funding from Australian Government Department of Health to rollout Decision Assist. Aim: to support health care professionals who work with older Australians living in the community • GP role is essential for achieving optimal patient and family outcomes in community based palliative care for aged care © Not to be used or modified without the permission of ANZSPM
- 4. Beginning of Time Percentage Risk of Dying 0 100 50 Timeline Individual’s lifetime risk of death since time began Today © Not to be used or modified without the permission of ANZSPM
- 5. Reframing palliative care © Not to be used or modified without the permission of ANZSPM
- 6. © Not to be used or modified without the permission of ANZSPM
- 7. Key processes to proactively manage clinical needs • Advance care planning (ACP) and documentation • Case conferencing and management plan documentation • Use of a terminal care management plan for patients at home or an end of life (terminal) care pathway for RACF residents © Not to be used or modified without the permission of ANZSPM
- 8. Decision Assist resources for GPs • Range of educational opportunities and resources for GPs – see Decision Assist website www.decisionassist.org.au • Palliative Care Phone Advisory Service (24/7) and Advance Care Planning Phone Advisory Service (8am-8pm 7 days per week) 1300 668 908 © Not to be used or modified without the permission of ANZSPM
- 9. Accredited educational activities • Clinical audit – pre and post audit using a framework based intervention • Active Learning Module (RACGP) / Theory Practice Activity (ACRRM) • RACGP: 40 Cat 1 QI&CPD points ACRRM: 30 PRPD points • Contact: karencooper.ANZSPM@bigpond.com © Not to be used or modified without the permission of ANZSPM
- 10. Other educational opportunities for GPs • Online ‘case of the month’ discussion This is an opportunity for GPs to participate in an online ‘case of the month’ discussion. The forum is moderated by a palliative medicine physician. Access: https://www.rrmeo.com/decisionassist • Videos An introduction to managing 4 common palliative care symptoms – pain, dyspnoea, nausea and vomiting, delirium www.decisionassist.org.au © Not to be used or modified without the permission of ANZSPM
- 11. Get the apps © Not to be used or modified without the permission of ANZSPM palliAGED gp •Prescribing and management advice to care for dying patients, and simple tools to identify older age patients moving into a palliative phase of care. palliAGED nurse •Support for nurses in general practice, community settings and residential aged care in providing a palliative approach to care. Available at the following stores: Google Play Apple iTunes More information and links to stores: www.decisionassist.org.au
- 12. Medications endorsed by ANZSPM – to use in terminal care in community-based patients © Not to be used or modified without the permission of ANZSPM MEDICATION CONCENTRATION PACKAGED as Clonazepam liquid* (oral drops) 2.5mg/ml 10ml bottle (2.5mg/ml) Clonazepam injection* 1mg/ml box of 5 ampoules Fentanyl citrate injection** 100mcg/2ml box of 5 ampoules Haloperidol injection 5mg/ml box of 10 ampoules Hydromorphone injection 2mg/ml box of 5 ampoules Hyoscine butylbromide (Buscopan) injection*** 20mg/ml box of 5 ampoules Metoclopramide injection 10mg/2ml box of 10 ampoules Midazolam injection** 5mg/ml box of 10 ampoules Morphine sulphate injection 10mg/ml AND 30mg/ml box of 5 ampoules * Non-PBS unless for seizure control ** Not on the PBS *** Non-PBS unless for colicky pain. Unrestricted via the Repatriation Schedule
- 13. Findings to date • Activities and marketing • Evaluation: – Process tracking indicators, reach – Framework based intervention outcomes © Not to be used or modified without the permission of ANZSPM
- 14. Activities and marketing • Delivery of GP and medical officers workshops 38 across Australia until 31/5/16 (2 more planned post- 30/6/16) • Delivery of Train-the-Trainer workshops 6 across Australia • Facilitation of trainer workshops 63 delivered/prepared to date • Delivery of practice nurse workshops 11 delivered © Not to be used or modified without the permission of ANZSPM
- 15. Activities and marketing • Factsheets: Think GP, HealthShare, DA website – Framework • Video – Framework and symptom management (short) • DA, ANZSPM and other newsletters • RACGP conference stand • Twitter line • Advertisements in GP magazines and ebulletins (e.g. Friday fax, CountryWatch) • Media releases (e.g. AMA AusMed newsletter, 6minutes) • DA marketing © Not to be used or modified without the permission of ANZSPM
- 16. Evaluation: process tracking indicators – reach • Workshop/ presentations Living Longer, Dying Better GPs attending = 4,904 (20% of full-time workload equivalent of GPs in 2013-14) • Other educational activities GPs accessing = 14,835 (64%) (excludes those accessing material via DA website and those accessing HealthEd online recordings) © Not to be used or modified without the permission of ANZSPM
- 17. Evaluation: process tracking measures – reach • TTT workshops: 96 MOs were trained, TTT manual uploaded to DA website so available to any GP training organisation • Workshops by state/territory: 15 Victoria, 2 Tasmania, 1 Western Australia, 21 Queensland, 3 Northern Territory, 2 South Australia, 19 New South Wales • Workshops by ARIA: 28 major city, 17 inner regional, 13 outer regional, 5 rural & remote © Not to be used or modified without the permission of ANZSPM
- 18. Evaluation: framework based intervention outcomes, short-term • Limitation: Longer workshops attracted those already interested in palliative care. According to questionnaire approx. 90% of those attending were already interested in provision of palliative care to older patients in the community & 79% interested in provision of palliative care for RACF residents. Shorter presentations, e.g. HealthEd, could not be evaluated. • Based on findings of 288 matched Pre/Post Workshop Questionnaires looking for self-rated changes to: Awareness of DA Knowledge Confidence © Not to be used or modified without the permission of ANZSPM Attitude Skills Intent to change practice
- 19. Evaluation: framework based intervention outcomes, medium term • Clinical audit - limited data to date, enrolled 77, completed 17 © Not to be used or modified without the permission of ANZSPM
- 20. Take home messages: • Decision Assist is an innovative clinically- based reform that is strengthening the ability of GPs to provide quality end-of-life care • GPs can use a framework of palliative care based on prognostic trajectories to proactively manage the palliative care needs of all Australians living in the community • Decision Assist offers GPs access to new resources and advisory services to inform their practice of palliative care © Not to be used or modified without the permission of ANZSPM
- 21. Thanks
Editor's Notes
- Key points A tender was released in 2013. The purpose of the tender is to improve the capability of aged care providers and GPs to provide palliative care and advance care planning for recipients of aged care living in the community. The tender is being run out by a consortium led by Austin Health and includes ANZSPM whose role is to develop palliative care educational activities and resources for GPs. Educational activities are based on the framework of care that has been adapted for the Australian clinical environment from the Gold Standards Framework (UK) and the framework of care contained within the Palliative Approach Toolkit for Residential Aged Care Facilities (RACFs) - that has been run out nationally for RACFs in Australia. The tender recognises that GPs are essential to optimal outcomes for elderly patients and their families. Further that GPs are well positioned to initiate and promote a palliative care approach to care for older Australians and to incorporate advance care planning into their routine care. Relevant participant handouts None Interactive activities None Relevant resources for facilitators Gold Standards Framework. [viewed 1 April 2015]. Available from: www.goldstandardsframework.org www.decisionassist.org.au The Palliative Approach Toolkit - Module 1: Integrating a palliative approach. Brisbane: The University of Queensland; 2012. (viewed on 29 June 2015). http://www.caresearch.com.au/caresearch/tabid/3591/Default.aspx
- Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba
- Key points When discussing the overall framework, the points to highlight are: The framework is based on three prognostic trajectories. Doctors know that prognostication is an inexact science, which is why the 3 trajectories are linked – if the prognostication is wrong, the patient is simply moved to another trajectory along the dotted lines. Each trajectory is associated with a key clinical process i.e. advance care planning, case conferencing (however configured) and a terminal care management plan. The framework is commenced by asking the trigger question “Would you be surprised if the person died in the next 6 – 12 months?” This question can be answered using clinical knowledge, personal knowledge of the patient as well as discussions with them, clinical intuition or a combination of all or some. If preferred, doctors can use or incorporate into decision making a needs assessment or prognostication tool such as the SPICT (Supportive and Palliative Care Indicators Care Tool) presented on the next slide. If the answer is “yes” to the surprise question, commence the first trajectory. If the answer is “no” to the surprise question, commence the second trajectory. The third trajectory is also included in a “no” answer, but as there is a diagnosis of dying, specific management plans are required. The third trajectory splits into 2 components depending on whether the patient lives at a private home or in a residential aged care facility. Throughout the discussion the emphasis should be that the framework is there to increase mindfulness of proactively managing clinical needs, rather than getting the prognosis exact. Indeed if incorrect or patient’s condition changes then follow the dotted lines and move to a new trajectory. Relevant participant handouts The diagram of ‘A Framework for Palliative Care in Community-Based Aged Care Patients’ (in Section 4 of Facilitator’s Guide) Interactive activities None Relevant resources for facilitators None
- Key points The key clinical processes will be discussed using a case study to illustrate how the framework could be used in clinical practice. HINT This is a good point to ask if there are any questions so far. Relevant participant handouts The diagram of ‘A Framework for Palliative Care in Community-Based Aged Care Patients’ (in Section 4 of Facilitator’s Guide) Interactive activities None Relevant resources for facilitators None
- Key points The Clinical Audit concerns the management of older patients with advanced life limiting conditions, both malignant and non-malignant, living in the community. There is a flyer in the handout packs concerning this audit that has been accredited for 40 Category One points by RACGP and 30PRPD points by ACRRM. The current workshop is an element in the clinical audit. RACGP members are required in this triennium to complete a quality improvement activity; a clinical audit is a quality improvement activity. HINT Please emphasise this clinical audit as we would like to encourage GPs to complete it. The data collected will be a valuable part of evaluation of the project. Relevant participant handouts Clinical Audit factsheet (in Section 4 of the Facilitator’s Guide) Interactive activities None Relevant resources for facilitators Clinical Audit factsheet (in Section 4 of the Facilitator’s Guide)
- Key points Online palliative care case of the month is open to all GPs. Cases include malignant and non malignant disorders. There are videos about managing 4 common end of life symptoms. Relevant participant handouts None Interactive activities None Relevant resources for facilitators Register to join the discussion about the online case of the month at www.rrmeo.com/decisionassist View videos: http://www.caresearch.com.au/caresearch/tabid/3227/Default.aspx#Videos
- Key points A mobile phone app has been developed. It contains prescribing and management advice for caring for older Australians at end of life. It can be downloaded via the usual shops. Relevant participant handouts palliAGED factsheet (in Section 4 of the Facilitator’s Guide) Interactive activities None Relevant resources for facilitators palliAGED factsheet (in Section 4 of the Facilitator’s Guide)