improving capacity for provision of community end-of-life care presented by professor liz reymond

PHC: Innovation and best practiceImproving capacity for provision of

community end-of-life careProf Liz Reymond MBBS (Hons) RACGP FAChPM PhD

Australian and New Zealand Society of Palliative Medicine Inc

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

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


Beginning of Time

PercentageRisk of Dying

0

100

50

Timeline

Individual’s lifetime risk of death since time began

Today


Reframing palliative care


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


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


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: [email protected]


Other educational opportunities for GPs

• Online ‘case of the month’ discussionThis 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, deliriumwww.decisionassist.org.au


Get the apps


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 PlayApple iTunesMore information and links to stores: www.decisionassist.org.au

Medications endorsed by ANZSPM – to use in terminal care in community-based patients


MEDICATION CONCENTRATION PACKAGED asClonazepam liquid* (oral drops) 2.5mg/ml 10ml bottle (2.5mg/ml)Clonazepam injection* 1mg/ml box of 5 ampoulesFentanyl citrate injection** 100mcg/2ml box of 5 ampoulesHaloperidol injection 5mg/ml box of 10 ampoulesHydromorphone injection 2mg/ml box of 5 ampoulesHyoscine butylbromide (Buscopan) injection*** 20mg/ml box of 5 ampoulesMetoclopramide injection 10mg/2ml box of 10 ampoulesMidazolam injection** 5mg/ml box of 10 ampoulesMorphine 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

Findings to date

• Activities and marketing

• Evaluation:

– Process tracking indicators, reach

– Framework based intervention outcomes


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


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


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)


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


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


Attitude Skills Intent to change practice

Evaluation: framework based intervention outcomes, medium term

• Clinical audit - limited data to date, enrolled 77, completed 17


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


Thanks

improving capacity for provision of community end-of-life care presented by professor liz reymond

Health & Medicine