Home' Australian Ageing Agenda : AAA Nov-Dec 2016 Contents Liz Forbat
the right support.
people may mean the
person is at higher
risk of developing new
problems. People with
dementia and other
forms of cognitive
impairment are at
even higher risk of
admissions happen because of a complex
mix of factors. A lack of planning for the
resident, a lack of access to GPs, poor
access to palliative care assessment,
inadequate access to palliative care
medicines, polypharmacy and adverse
drug reactions are some common reasons.
Aged care staff often do not have the
skills to identify deterioration or diagnose
dying, therefore the default is to send the
person to hospital.
In response to all of this, Calvary Health
Care ACT and The Calvary Centre for
Palliative Care Research developed and
tested a novel and innovative approach
to integrating special palliative care into
residential aged care.
In 2014-15 we piloted a palliative
care nurse practitioner to help aged care
facilities triage their residents most at risk
of dying with poorly controlled symptoms.
The nurse practitioner is a palliative
care specialist with the ability to prescribe
palliative care medicines and to de-
prescribe non-essential medications, in
collaboration with the person's GP.
The integrated model of care consisted
of a number of components (see 'Model of
REDUCED HOSPITAL STAYS
Our new model of care substantially
reduced people's length of stay in hospital.
There was a 45 per cent reduction in
average length of
hospital stays (an
average of 2.17 days
For residents who
were discussed at a
needs round, length
of stay in hospital
dropped by 67 per
cent -- meaning an
average of 3.22 days
less in hospital.
estimate of cost saving due to decreased
hospital bed occupancy was $115,539 over
three months. We also achieved 100 per
cent of residents dying in their preferred
place of death.
The approach also showed that staff
were more able to normalise death and
dying; they became more able to understand
that supporting residents who are dying and
their families is part of their work.
Staff understood the dying process
better, and learned more about how to
speak to families about death and dying.
Staff also reported they gained knowledge
from being supported by the palliative
care nurse practitioner so that their own
capacity was strengthened.
Having a palliative care specialist who
was able to prescribe essential anticipatory
medications and provide relief from
pain and suffering was valuable: pain
and symptom management improved
and residents' needs were able to be
anticipated and met in a timely manner.
Medications, such as morphine
injections, were ordered and held in
the facility specifically for each resident
dependent on their anticipated need.
As communication improved facilities
received fewer complaints from relatives.
Further, better decision-making and
planning for life and death was found
to improve living and reduce avoidable
For people like Valarie, having access
to specialist palliative care clinicians could
substantially improve their symptoms,
support staff and reduce hospital costs.
There are some key implications of our
study's outcomes for both aged care
providers and aged care policy makers.
First, people living in residential aged
care deserve the same access to specialist
palliative care services as the rest of the
community, and this needs to be funded.
Our approach offers a cost-effective
solution that prioritises high quality
care, reducing days in hospital while
maximising symptom management within
the aged care facilities.
Second, the latest ACFI funding cuts
may reduce residents' access to primary
palliative care. Facilities relied on funding
within the ACFI's Complex Health Domain
to provide in-house palliative care.
A worrying outcome of the change in
funding is that it may become more cost
effective for facilities to send residents to
hospital for symptom management or end
of life care. n
Nikki Johnston is a palliative care nurse
practitioner at Calvary Health Care ACT
and Professor Liz Forbat is director of the
Calvary Centre for Palliative Care Research.
Model of care: key components
Palliative care needs rounds: monthly
60-minute triage and risk stratification
meetings, where up to 10 residents who
were at risk of dying and were experiencing
a high symptom burden are presented
by facility staff to the palliative care nurse
practitioner. Residents did not attend.
Discussions focused on treatment/symptom
management and planning for end-of-life
care. Residents and families who would
benefit from a case conference were
identified, and referrals to other agencies
were also made.
Case-based education for staff: education
was offered within the needs rounds, at the
bedside and in case conferences. Education
focused on issues including communicating
with residents, relatives and GPs, symptom
management approaches, identifying
deteriorating patients and dying.
Case conferences: meetings were
between facility staff, residents, relatives
and relevant health care providers. Case
conferences were attended and facilitated
by the nurse practitioner at the beginning of
the intervention, to model how to conduct
the meetings. As the facility staff gained
confidence, they took over the chair
function, and the palliative care NP was only
involved when resident/family had complex
physical, psychological or social needs.
The agenda focuses on resident and/
or family concerns, moving to discussion
of how quality of life could be improved,
goals of care (including discussion about
hospitalisation), and completion of an
advance care plan.
Direct clinical work: with residents,
which includes symptom assessment,
diagnosis, symptom management. It
also involves support and education
for families. Both palliative care needs
rounds and case conferences may lead to
referrals for direct specialist palliative care
clinical work with residents.
A conservative estimate of saving due
to decreased hospital bed occupancy
was $115,539 over three months.
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