pathways to palliative care in rural victoria · the nurse practitioner (np) program is well...

Pathways to specialist palliative care in rural regions – Gippsland Region

Pathways to palliative care in rural Victoria Gippsland Region Report

Date submitted: 28th February, 2019

Contact: Anny Byrne, GRPCC Consortium Manager

Pathways to palliative care in rural Victoria – Gippsland Region

1 | P a g e

Contents 1. Executive Summary ..................................................................................................................... 2

2. Background ................................................................................................................................. 4

2.1 Policy Context ..................................................................................................................... 4

2.2 Gippsland Region Overview ................................................................................................ 5

2.3 Palliative Care Services in Gippsland Region ...................................................................... 6

3. Purpose of the project ................................................................................................................ 8

4. Objectives .................................................................................................................................... 8

5. Governance ................................................................................................................................. 8

6. Methodology ............................................................................................................................... 9

7. Findings / What the data showed ............................................................................................. 10

7.1 Existing pathways to palliative care inc. Consultancy ....................................................... 10

7.2 Commonalities, differences and gaps in existing pathways ............................................. 12

7.3 Barriers and enablers of regional palliative care access ................................................... 13

8. Discussion .................................................................................................................................. 14

8.1 Discoveries ........................................................................................................................ 14

8.2 Gaps .................................................................................................................................. 18

8.3 What can be changed now to promote consistency ........................................................ 19

8.4 What can’t be changed now and why .............................................................................. 19

9. Conclusion ................................................................................................................................. 19

This report has been prepared by:

Anny Byrne, Manager GRPCC, Carol Barbeler Palliative & Aged Care Resource Nurse GRPCC,

Leearna Earwicker, Project Worker GRPCC and input from stakeholder representatives of the GRPCC

Clinical Practice Group, GRPCC Consortium Managers Group, GRPCC Community of Practice and the

Gippsland Regional Consultancy Service.


2 | P a g e

1. Executive Summary The Department of Health and Human Services commissioned this project funding across the five

regional palliative care consortia, with each consortium receiving a grant of $25,000 to work

collaboratively to identify and compare pathways to palliative care and consultancy services

across the regional areas. The purpose of the project is to identify immediate and future

opportunities for making pathways to palliative care more consistent across the rural regions and

inform future policy.

There are eight funded specialist palliative care community care services in Gippsland, and

eleven funded palliative care inpatient beds and a regional palliative care consultancy service.

In the community setting, most service models consist of palliative care nurses, either clinical

nurse consultant, clinical nurse specialist or nurse practitioner, working together with GPs and

district nurses to provide palliative and end of life care. They are augmented by the Gippsland

Regional Palliative Care Consultancy Service (GRPCCS) who provide primary and/or secondary

consultation for complex palliative care patients to designated community and inpatient

services, through palliative care physicians, nurse practitioners, clinical nurse specialists and,

specialist social workers.

There are many variations across the region regarding access and provision of palliative care

services. With issues differing in each subregion, it is difficult to quantify the challenges region

wide.

The main findings were:

There is a lack of admission criteria to palliative care beyond ascertaining that referrals

come from a doctor or are supported by a doctor despite the existence of a ‘Gippsland

Region Palliative Care Consortium (GRPCC) Palliative Care Referral / Triage Tool’.

There appears confusion and a lack of consumer knowledge about what palliative care is,

and what it can offer both in breadth of service delivery and limitations.

The process of referral to palliative care is ad hoc and dependent on referrer and the

service accepting; there is no minimum data set used across the region which impacts on

triage, and service provision.

The GRPCCS is in its infancy and challenged by medical palliative care consultant

recruitment and retention issues at present. As it becomes more established the access

and referral will become more streamlined, regional multidisciplinary team (MDT)

meetings will occur and outpatient clinics will be established.

There is a lack of generalist as well as specialist routine psychosocial and bereavement

support.

The Nurse Practitioner (NP) Program is well established and provides high impact

support to local palliative care services and GPs particularly in the absence of palliative

care medical practitioner support.

Transition of end of life care from hospital to home remains a challenge and

opportunity, particularly in the urgent care setting.

Admission and Discharge communication and processes from health service to health

service, hospital to home, home to hospital, within the region, and from metropolitan

centres requires streamlining and improvement. There is a lack of electronic palliative

care records to facilitate streamlined after hours consultancy support.


3 | P a g e

All health services are currently using the Care Plan for the Dying Person to guide

terminal care. A consistent audit tool is required to gather data across the region to

inform practice.

There appears a discrepancy and confusion in some services regarding the pathway for

early admission to palliative care service for clients with non-malignant chronic disease.

There is a gap in volunteer and respite options. There is a lack of knowledge around

application of flexible models for respite available outside of aged care.

There is a wide variation in the knowledge, understanding and skills across health

practitioner disciplines regarding palliative care.

The main recommendations that can be implemented now to promote consistency and reduce

unwarranted variations in care:

Implementation of a consistent agreed referral pathway to palliative care services and the

consultancy service with a completed minimum information dataset.

Implementation of a consistent triage tool to guide urgent and timely admission to

palliative care services, informed by the Palliative Care Outcome Collaborative (PCOC)

data set and Symptom Assessment Scale (SAS).

Consistent feedback to GPs to ensure communication is improved, inclusive and timely.

Clarification, streamlining and alignment of chronic disease management programs with

palliative care programs to ensure timely and appropriate referral to palliative care, and

effective care coordination.

Increased inclusion of interdisciplinary care planning including aboriginal health workers

particularly for clients with chronic disease to reflect the diversity in palliative care client

requirements.

Communication strategy to ensure the successful implementation of the above – working

with Primary Health Networks Health Pathways Project; GRPCC Community of Practice

forum; GP practices; community palliative care services and health services.

Support the further development of the Nurse Practitioner in Palliative care program in

Gippsland to build capacity for the future.

Scoping and development of telehealth opportunities based on other regional successes.

Increased diversity of practitioner knowledge in palliative care services, targeting

subacute disciplines and streams of care, including degenerative neurological disorders,

renal disease and chronic disease management clients, to recognise the changing needs

of clientele with multiple co morbidities.

Scope the availability of home respite care services in other regions and explore the

opportunity for them to be established in Gippsland.

Continue to support the training, development and management of the palliative care

workforce, including volunteers, in Gippsland.


4 | P a g e

2. Background

2.1 Policy Context Numerous strategic documents guide the implementation of end of life and palliative care service

in the State. The key guiding document for Victoria - Victoria’s end of life and palliative framework

(Department of Health and Human Services Victoria, 2016) outlines the goals, priorities and

actions to lead improvements in high-quality end of life care for all Victorians. The Framework

emphasises the need for service providers to connect and work together to develop innovative

new strategies to deliver care focused on a person-centred approach. Acknowledging that end of

life and palliative care is everyone’s responsibility, the framework outlines plans for service re-

design to enhance end of life and palliative care as part of a coordinated and integrated health

service system.

Other documents and standards that support the implementation of high quality end of life and

palliative care specific to service sectors include but are not limited to:

Advance care planning: have the conversation – A strategy for Victorian health services

2014 – 2018.

National Consensus Statement: Essential elements for safe and high-quality end-of-life

care, 2015.

National Safety and Quality Health Service Standards (2nd edition, 2018), Australian

Commission on Safety and Quality in Health Care. (Particularly Standard 5 -

Comprehensive Care).

Aged Care Quality Standards.

National Palliative Care Standards (5th edition, 2018).

Strengthening care for children with a life-threatening condition: A policy for health,

palliative care, disability, children’s services and community care providers 2008 – 2015.

After-hours palliative care framework, 2012.

Bereavement support standards for specialist palliative care services, Victorian

Department of Health 2012.

Strengthening palliative care: palliative care volunteer standards, 2007.


5 | P a g e

2.2 Gippsland Region Overview

Demographics

In 2016, the resident population in Gippsland was 271,052 persons or 4.6% of Victoria’s total

population. 27.3% of residents are aged 60+. The projected change in population is 1.4% per

annum, resulting in an estimated resident population of 333,210 persons in 2031.

An overall Gippsland and annual growth rate 2016-2021 of 1.4 % (compared to 1.7% of state

average) is projected, with Baw Baw Shire and Bass Coast expecting increases of 2.8% and 2.4%

respectively; 2.0% of Gippsland’s projected proportion of population will have dementia by 2020

compared to the 1.6% state average; a 1% greater state average of Aboriginal and Torres Strait

Islanders population in 2011; and a 20% greater than the state average diagnosis of malignant

cancer per 100,00 population in 2012. Gippsland has a lower male life expectancy than the

Victorian average with the Gippsland Region (84 years for women; 78.1 years for men) and Victoria

(84.4 years for women; 80.3 years for men (DHHS, 2018) DHHS, 2015c).

Geography

The Gippsland region is extremely diverse, covering an area of 41,375 square kilometres (18.3%

of Victoria), from the Bunyip River in the west, to the New South Wales border in the east. The

distance from Mallacoota in the east to Melbourne CBD is approximately 516 km.

Traditional Owners/CALD Statistics

The diversity of Gippsland communities is reflected in their locations, ranging from the remote

areas of East Gippsland to the coastal areas of South Gippsland, from the burgeoning housing

estates of West Gippsland to the hills of the Strzelecki Ranges. Populations include farmers,

miners, professionals, people who are unemployed, retirees and tourists.

While being more ethnically homogenous than the other regions, Gippsland has a higher than

average percentage of Aborigines. Aboriginal communities are dispersed throughout the region

with the greatest number living in East Gippsland and the smallest in South Gippsland.

There are approximately 3,000 Gunai Kurnai people located in Gippsland and are made up of five

major clan groups.

Figure 1: Gippsland Population for

Gippsland LGA’s

Source: Gippsland PHN Priorities 2016-18 Snapshot


6 | P a g e

Social Disadvantage

According to the Socio-Economic Indexes for Areas (SEIFA), an ABS product that ranks areas in

Australia according to relative socio-economic advantage and disadvantage, areas within

Gippsland are ranked to have amongst the highest levels of social disadvantage in Victoria

(https://www2.health.vic.gov.au/about/publications/data/Gippsland-Region---SA2s-SEIFA-

scores-by-LGA ).

Deaths

There were a total of 2,518 deaths/year in Gippsland as an average between 2006 and 2016. This

represents 6.3% of total deaths in Victoria over the ten-year period. Since 2001, an increase in the

number of deaths in Gippsland is evident. Within Gippsland local government areas Latrobe City

has the highest average number of deaths per year at 594, followed by East Gippsland (451), and

Wellington (369)

2.3 Palliative Care Services in Gippsland Region There are eight designated community palliative care services in the Gippsland region (Figure 3)

and eleven designated palliative care inpatient beds.

Health Service Rating Funded Community

Palliative Care Service

Number of inpatient Palliative Care Beds

Bairnsdale Regional Health Service (BRHS) Sub Regional Hospital √ 2

Bass Coast Health (BCH) Sub Regional Hospital √ 1

Central Gippsland Health Service (CGHS) Sub Regional Hospital √ 2

Gippsland Lakes Community Health (GLCH) Stand Alone Community Health Centre

√

Gippsland Southern Health Service (GSHS) Small Sub Regional √ 1

Latrobe Community Health Service (LCHS) Stand Alone Community Health Service

√

West Gippsland Healthcare Group (WGHG) Small Sub Regional √ 2

Yarram and District Health Service (YDHS) Small Sub Regional √

Latrobe Regional Hospital (LRH) Regional Hospital 4

Bass Coast,

309, 14%

Baw Baw, 311,

14%

East

Gippsland

451, 20%

Latrobe, 594,

26%

South

Gippsland

239, 10%

Wellington 369, 16%

Figure 2: Average number of deaths per year for

Gippsland LGAs, 2006-2016.

Source: Australian Bureau of Statistics, Cat 3302.0. Data Cube:

Deaths, Summary, Local Government Areas-2006 to 2016;

https://www2.health.vic.gov.au/about/publications/data/Gippsland-Region---SA2s-SEIFA-scores-by-LGA

https://www2.health.vic.gov.au/about/publications/data/Gippsland-Region---SA2s-SEIFA-scores-by-LGA


7 | P a g e

Generalist palliative care services are also provided by Omeo District Health (ODH), Orbost

Regional Health (ORH), South Gippsland Hospital (SGH) and Koo Wee Rup Health Service (KRHS).

Smaller services in the East Gippsland region who are not funded to provide specialist palliative

care, including bush nursing services, are directly supported by Gippsland Lakes Community

Health through the Nurse Practitioner and psychosocial support worker roles. Coverage of after-

hours support for these more remote service is fraught with difficulties in relation to the tyranny

of distance.

Figure 3: Location of palliative care services - Gippsland region

Gippsland Regional Palliative Care Consultancy Service (GRPCCS)

Prior to the establishment of the Gippsland Regional Palliative Care Consultancy Service (GRPCCS)

2015, a palliative care consultancy model was developed and managed by the GRPCC from 2009-

2015, in collaboration with Calvary Bethlehem Health Service, Peninsula Health, and Monash

Health.

In 2015, the Department of Health and Human Services (DHHS) appointed Latrobe Regional

Hospital (LRH) as the service responsible for palliative care consultancy service provision in

Gippsland and the GRPCCS was established. The GRPCCS provides specialist palliative care

consultancy service to all regions of Gippsland in the form of scheduled visits and an after-hours

telephone on call service. The GRPCCS collaborate with existing local community based and

inpatient palliative care services and aim to provide specialised consultancy interdisciplinary

palliative care to patients and their families according to their preferences and goals. Currently,

the GRPCCS is staffed by a palliative medical consultant; Nurse Practitioners; Clinical Nurse

Consultants; Specialist Social Work and administration support.

See Appendix A- Palliative Care Services Staffing Profiles


8 | P a g e

3. Purpose of the project In November 2017, the then Minister for Health, the Hon. Jill Hennessy MP announced an

investment of more than $62 million in additional funding over five years to give people with life-

limiting illness more options to be cared for, and to die, in their place of choice. This funding

announcement included a commitment to address gaps in palliative care for people living in rural

areas.

The Department of Health and Human Services (the department) allocated $125,000 from this

funding across the five regional palliative care consortia, with each consortium receiving a grant

of $25,000 to support this quality improvement project.

The department requested each of the five rural palliative care consortia in Victoria to work

collaboratively to identify and compare pathways to palliative care and consultancy services

across the regional areas.

To identify immediate and future opportunities for making pathways to palliative care more

consistent across the rural regions.

Results from this project will identify opportunities for changes to make pathways more consistent

and inform future policy.

The objectives of this project are to achieve consistent pathways for referral to palliative care

services across the rural regions. The outcome of this work is to enable identification of

opportunities for quality improvement / or change and to inform future palliative care policy.

4. Objectives To identify:

Existing pathways to palliative care including consultancy in each regional area.

Identify commonalities, differences and gaps in existing pathways.

Identify barriers and enablers of regional palliative care access from a health professional perspective.

Identify barriers and enablers of regional palliative care access from a consumer perspective.

Identify what can be changed now.

5. Governance The Regional Pathways project used the existing structures and functions of Clinical Advisory

Groups as the steering committee.

The project officer provided:

Monthly status reports to the Chair and Management Group of each Consortium.

Monthly verbal reports to Clinical Practice Groups of each Consortium.

Monthly verbal reports to the DHHS.

6 weekly reports to the Consortium Managers group.


9 | P a g e

Final BSW region report forwarded to the Consortium and to the Chair and Management

Group of each Consortium.

The final report from the five regional Consortia will be forwarded to DHHS by the lead

Consortia.

6. Methodology Each of the five regions undertook the following actions with agreed actions/tools to

ensure consistent findings:

Develop state-wide palliative care pathway survey questionnaire.

Develop a common template for regional stakeholder mapping.

Audit pathways to palliative care services and consultancy services, including respite,

in each of the five regions.

Identify what is working well, challenges and barriers for consumers of palliative care.

Compare and identify commonalities, differences and gaps in referral pathways across

the five regions.

Regional stakeholder mapping – common template.

Stakeholder engagement (interviews, focus group discussions, existing recent reports,

survey results).

Common AUDIT (survey) of referrers.

Analysis of issues.

Production of local report.

Collaborate in the production and review of draft and final report to DHHS.

Financial acquittal.

Collectively, the regional consortia worked on:

Development of the audit matrix, survey tool, and template for stakeholder mapping.

Compilation of issues into a report by region.

One consortium will take the lead to compile the individual reports into a thematic

summary.

The final report will consist of a collaborative report on outcomes of the audit with

individual regional reports as appendices.

Mapping of results will be against agreed domains. Each region may also use existing

relevant reports and documents from engagement undertaken since 2015.

The GRPCC appointed a project worker with the money allocated for the project to work one

day/week for the duration of the project.

Two separate surveys were developed: Palliative Care Services (including consultancy services)

and the Generalist Workforce in Healthcare. The Generalist workforce included GP’s, Allied

Health, Case Managers, Peak Bodies/organisations, Aged Care nurses and managers, Aboriginal

Community Controlled Health Organisations (ACCHO’s), Medical Specialists, Tertiary Hospitals and

Disability Support Professionals. The surveys were circulated early in November, 2018 and closed

on 30th November, 2018.


10 | P a g e

Consumers were not surveyed as part of this project due to the recent ‘Patient and Carer

Experience Survey’. It was felt another survey at this time would seem too overwhelming for

consumers and therefore potentially generate a poor response. Data from the Patient /Carer

Experience Survey is expected to be made available to services in March 2019. We intend to

incorporate relevant data from this survey in to the overall report to DHHS which will compare all

rural palliative care services in each of the five regions.

Survey Responses in Gippsland

The Palliative Care Services survey generated 8 responses:

Community Palliative Care Services- 7

Regional Palliative Care Consultancy Service-1

The Generalist Workforce in Healthcare survey generated 302 responses from a broad range of

respondents including from health professionals, inpatient palliative bed staff, medical specialists,

residential aged care facilities, aboriginal health workers and case managers.

(See Appendix B for details).

Additional Sources of Information

The GRPCC has been able to draw on several other projects and activities that have been

completed within the region since 2015 to inform, validate, and corroborate the data and findings

that have been elucidated from the state-wide survey. A desktop review was undertaken of the

following projects:

GRPCC ‘A Model of Care for Community Palliative Care in Gippsland. Part 1-Report.’

2015 (see Appendix C).

GRPCC Community Palliative Care Service Gaps 2017 (see Appendix D).

Collaborative Palliative Approach Referral Pathways Project 2017-18 (see Appendix E).

A snapshot of access to community palliative care in Gippsland -January 2019

(see Appendix F).

Research article provided by Monash University Department of Rural and Indigenous

Health, as a result of ongoing collaboration. ‘Challenges associated with anticipatory

medications in rural and remote settings’, conducted in Gippsland, and to be published

in 2019 (see Appendix G).

7. Findings / What the data showed

7.1 Existing pathways to palliative care including consultancy 7.1.1 Access to service information

Information related to service provision and location was accessed from local health service

websites, the Gippsland Region Palliative Care Consortium (GRPCC), Palliative Care Victoria (PCV),

Palliative Care Australia (PCA), Department of Health and Human Services (DHHS), & Victorian

Aboriginal Community Controlled Health Organisation (VACCHO) respectively. Respondents

reported the local services websites were more up to date than PCV/PCA/DHHS websites, in

regard to service provision, contact details and locations for access to service information.


11 | P a g e

7.1.2 Referral to palliative care

All community palliative care services will accept referrals from self, carer/family member, GP,

Medical Specialist, nursing, and Allied Health professionals.

All community specialist and generalist palliative care services accept referrals by letter or secure

electronic referral (S2S), GRPCC referral form, phone call, fax and email. Most services stated

they prefer the SCTT as their specific template tool. There was no consistency between services

of a common dataset of information to be provided for referral (see ‘Snapshot of urgent referral’

Appendix F).

Referrals to GRPCCS are made by phone, letter, or by fax. GPs who refer to the Gippsland

Regional Palliative Care Consultancy Service (GRPCCS) are mostly utilizing phone support referral

for specialist consultation.

There was no specific survey question related to the triage of palliative care referrals. Survey

results and additional information identify barriers to access and service provision related to

difficulty in referring, referrals not being accepted, waiting lists, and lag times between referral

and delivery of palliative care. One palliative care service identified their use of a triage tool for

referrals to community palliative care. See appendix F for a ‘snapshot of urgent palliative care

referral relating to intake, information needed, and triage processes’ at each of the funded

palliative care services that the GRPCC undertook in late January 2019.

In 2017-18, the GRPCC undertook a project to map a pathway of referral from Residential Aged

Care Facilities (RACF) to specialist palliative care, via local palliative care services, for residents

with complex or unmet palliative care need. See Appendix B for further information.

7.1.3 Reason for referral

The main reasons for referral to palliative care services from GPs, Allied Health professionals, RACF

managers and nurses were: end of life/terminal care; complex symptoms; person wanting to be

supported to die at home; and complex bereavement/psychosocial needs. Additionally, allied

health professionals and GPs identified after-hours needs, and GPs specifically indicated carer

capacity as triggers for referral. Nurses specifically identified that an end of life care needs

assessment for a person living at home would trigger referral to community palliative care.

Survey respondents identified the triggers for referrals to specialist regional palliative care

consultancy service include: complex symptoms and need for specialist palliative care;

psychosocial support; carer capacity; and after-hours needs.

Reasons why referrals to community palliative care were denied admission to palliative care

included: those clients living beyond service area/too far away; staff safety issues contributing to

an occupational health and safety issue to do home visits; considered too early for referral

(prognosis greater than 6 months); inadequate referral information; patient/family/health

professional have unrealistic expectations of service available (e.g. referral made to access in-

home equipment like oxygen/electric beds rather than symptom management); and confusion by


12 | P a g e

some health professionals regarding criteria for admission to palliative care for clients funded

under more than one program stream (e.g. HARP/Palliative Care).

7.1.4. Transition between service providers for palliative care

Responses from nurses working in inpatient units in transitioning palliative patients to home

indicated an inconsistent approach, unless the patient is already known to the local community

palliative care service. Unless they are already registered with the local service, issues have been

identified in a lag in response time, ad hoc referral processes, and confusion around the referral

process/pathway. Anecdotally, the lack of geographical awareness of Gippsland, the process of

referral and admission to the local palliative care service, and the services’ capacity to respond,

are factors in the difficulty of facilitating support in the transition from hospital to home. Issues

have also been identified in the provision of adequate referral information from regional hospitals

to health service (within Gippsland), and metropolitan to regional or local services.

7.1.5 Streamline access to palliative care

Most GPs had referred to community palliative care, but nearly half preferred to ‘palliate their

own’ patients’. This preference to palliate their own patients was also echoed by medical specialist

respondents. Some GPs and medical specialists had referred to the consultancy service, and

nearly half of GPs said ‘there were no barriers in accessing palliative care in their area.’ Other GPs

indicated factors in accessing palliative care included issues associated with the large geographic

area of Gippsland, poor after - hours palliative care coverage, understaffing and not knowing the

referral process.

Nearly half of the RACF respondents contact local Community Palliative Care if the GP was not

available for person entering terminal phase. Aboriginal Health Worker respondents and disability

support professionals with clients who have required access to palliative care have some

awareness of the process, and had support from their GPs for referral.

Both Allied Health professional respondents and case managers believed that they had clients in

the last 12 months of life and had contacted Community Palliative Care. Issues were cited of clients

with advanced chronic disease being admitted to District Nursing (DN) services rather than to

palliative care, despite palliative care referral. It is suggested that a lack of skills and understanding

of the needs of people with advance chronic disease, and recommendations of early referral to

palliative care, results in poor information provision to GPs and the potential need for emergency

care in the last few weeks of life.

7.2 Commonalities, differences and gaps in existing pathways

Survey responses identify that most Community Palliative Care Services provide palliative care

client assessment, home nursing care, phone assessments, family support, after hours phone

advice and after hours visits and bereavement follow up including referral to bereavement

counselling. This is consistent with the Model of Community Care report (2015), although there

is some disparity in the availability of psychosocial support/bereavement follow up/access to


13 | P a g e

bereavement services between the palliative care service survey, and the feedback on

availability/access to appropriate grief and bereavement services in the generalist healthcare

survey results. Health professionals indicated there are challenges and waiting lists for

psychosocial support. It is suggested that the newly formed GRPCCS grief and bereavement

specialist program has not developed a level of service consistency that is being reflected in health

professional or stakeholder feedback.

Different and inconsistent referral processes (within services/within Gippsland/from metro

services), the form and type of information required and provided on referral, response times for

referrals and triage process appear different between palliative care services, inpatient palliative

care beds, and the GRPCCS. This lack of consistency and systematic approach impacts on

coordination and timely access and delivery of palliative care.

One community palliative care service indicated that they did not provide services to RACF,

despite the region wide referral pathway project in 2017-18, and involvement of all services in the

regional mapping project. The GRPCCS will provide phone advice along with onsite consultancy

visits to RACFs.

Community Palliative Care services utilized telehealth (two services for primary consults, the

remainder for projects/meetings). GRPCCS do not utilize telehealth and only one inpatient service

utilized telehealth for emergency presentations.

Survey respondents indicated that in-home respite, and day respite services were very difficult to

access, or non-existent. In-patient respite services in Gippsland for clients under 65 and not

privately insured are difficult to identify or access. There is availability of respite beds in RACF and

accessing these requires assessment from Aged Care Assessment Services (ACAS) for clients over

65 years of age via My Aged Care directly or referral from the GP or health care professional.

Clients with private health insurance can be admitted to a private hospital, however, this is a less

likely scenario in Gippsland. Some sub regions have adopted flexible funding models to provide

carer respite in home.

There are a number of patient management systems used within Gippsland. Community Palliative

Care services are predominately using UNITI, with TCM7 and PJB the other software programs in

use. More than half the services are using iPM as their inpatient management system, with

BOSSNet, and Trackcare used in the Emergency Department.

The GRPCCS uses iPM along with paper records. A specific palliative care patient web based e-

management system, ‘PALLCARE’ has been considered for implementation and continues to be

investigated for secure and effective sharing of palliative care information of clients referred to

the GRPCCS.

7.3 Barriers and enablers of regional palliative care access

The Gippsland Regional Palliative Care Consortium (GRPCC) was identified as an enabler in the

provision and access to palliative care in Gippsland, as was a ‘good GP service’. Education and the

knowledge of when and how to refer, the same referral pathways across regions, access to and

sharing of information (clinical and care planning), partnerships and collaboration were seen as

essential to improving access to palliative care. The Palliative Aged Care and Disability Resource


14 | P a g e

Nurse provides support and capacity building in RACFs, and in the disability environment. The

MND shared care resource worker provides support and a conduit to palliative care services.

More than 50% of the health professional respondents recognized an increase in the need to

contact palliative care services. There appeared a delay in admitting identified palliative care

patients in a timely fashion with a mismatch of the palliative care needs of the patient. An example

is a chronic obstructive pulmonary disease patient being referred to palliative care but placed on

District Nursing monthly checklist rather than triaged as a palliative care patient. Early palliative

care referral is sometimes doubted or disagreed upon for people with chronic illnesses by other

health professionals, GPs, and medical specialists. Although early referral to palliative care is

encouraged; early access to palliative care is prohibited by lack of resources, variations in trained

staff, and inadequate workforce to support homecare and lack of specialist palliative care

physicians.

Generalist healthcare professionals collectively identified lack of knowledge of the services

available, being unsure of referral processes, including when to refer, and the length of time from

referral to admission, as being challenges to accessing palliative care. Other responses included

the poor across-service and interdisciplinary engagement and communication. Respondents

identified that well developed communication processes and care coordination across all

stakeholders would enable an increase in access to timely palliative care in this region.

Some GPs commented that there is a disconnection between community palliative care services

and the GP, and the need for better liaison with palliative care services. Some GPs responded that

they felt they were ‘not part of the care or planning once the person was referred to palliative

care, or an inpatient’, or ‘we are only consulted for scripts at end of life’. This is validated by the

GRPCC Emergency Medication Audit and Report of 2012, and then confirmed in current research

conducted by Monash University in Gippsland and published in 2019 (see Appendix G). This shows

there is little consensus among GPs and nursing staff, from the different health services, regarding

approaches and protocols to anticipatory prescribing and obtaining supplies of emergency

medications.

Interestingly, nurses, allied health professional, case managers, disability workers, aboriginal

health workers and RACFs all identify that a major barrier to referral to palliative care is

patient/family refusal (between 15-50% of each stakeholder group). Limited patient, family, or

carer knowledge regarding ‘what is palliative care,’ and the lack of community knowledge of what

palliative care services offer is often incongruent with consumer expectations of the service.

Medical Specialists and GPs identified workforce capacity and service shortages as a barrier to

accessing palliative care. GPs also identified poor coverage over 24 hour period by palliative care

nursing services, the large distances and time constraints of the region, along with the need for

capable carers/family to enable a person to be supported in end of life care in the community.

The variation in skill mix of the providers of generalists providing palliative care was also seen as

a barrier to access.

8. Discussion

Discoveries There are many variations across the region regarding access and provision of palliative care. With

issues differing in each subregion, it is difficult to quantify the challenges Gippsland wide.


15 | P a g e

Despite the geographical challenges in Gippsland and the recent iteration and evolution of the

Gippsland Region Palliative Care Consultancy Service (GRPCCS), palliative care providers across

Gippsland continue working toward the GRPCC Model of Community Palliative Care 2016 to

strengthen and consolidate service provision and workforce. The development of the GRPCC

Community of Practice in 2018 has provided a forum for palliative care systems and processes to

be shared between key palliative care leaders to inform best practice and reduce unwarranted

variations in care.

The maturing and evolving GRPCCS is working collaboratively with all stakeholders to ensure

access to specialist palliative care service is available region wide in community, inpatient and

RACFs. There are plans to commence outpatient Nurse Practitioner led palliative care clinics and

regional multi-disciplinary team meetings linking in the subregions. The GRPCCS are currently

visiting the local community palliative care services systematically to provide support, assistance

and capacity building.

The Nurse Practitioner (NP) role has added great value in the continuity of palliative care service

delivery, particularly with the workforce palliative care physician recruitment gaps in Gippsland.

The NPs have provided significant impacts on improving the efficacy of palliative care in the

community setting, with GPs, in the inpatient setting, as well increasing skill level and building

capacity of their nursing and allied health colleagues.

The Consortium Managers Group (2017), survey highlighted the lack of ability to use the palliative

care funding flexibly and responsively across community and acute settings when the same health

service provides both services. This presented barriers for the health service to be responsive to

the patient’s needs. An example is one small health service with a strong community palliative

care service may not use all their inpatient bed days but they may overspend in community

palliative care. Gippsland also has unfunded services and small bush nursing centres who provide

palliative care to their community when needed, but have to fund this from their other collective

funding sources.

8.1.1 Knowledge There appears confusion and a lack of consumer knowledge about what palliative care

is, and what it can offer both in breadth of service delivery and limitations.

Survey responses indicate some confusion regarding referral appropriateness and

timeliness to palliative care for non-malignant, chronic disease patients.

Service information is accessed through all web sources but local health and community,

and local organisation websites have the most up to date information.

According to survey respondents The GRPCC website and information was utilised often

by many service providers to obtain relevant and current information.

8.1.2 Referral information Pathways to Palliative Care in the Gippsland region can be ‘ad hoc’ and dependent on

who is working on the day’. There appears to be a lack of uniform referral processes,

pathways or template tools for referral utilised across the region. In some services it was

identified there are no formal triage processes within palliative care services. Despite

the development of referral tools and processes by the GRPCC CPG, there remains a lack


16 | P a g e

of consistency, knowledge and implementation around referral requirements in some

areas.

All health services and the consultancy service accept a variety of referrals (phone, S2S,

fax, email) to their service without a required and completed minimum data set. This

requires inefficient use of clinician time ‘chasing up‘ to complete information required

for the receiving service and has an impact on admission, access and triage.

Some smaller health services have consistent and accepted systems and processes

regarding referral due to pre-existing relationships with the referrer.

8.1.3 Access to palliative care service provision There appears to be confusion and unclear pathways for chronic disease patients

accessing palliative care and incongruence between funding streams. An example given

is the understanding that a patient currently on HARP program cannot be on community

palliative care even though they may require input from both services.

There continues to be a misconception that some community palliative care providers

do not provide care in RACFs. Lack of staff resources has been a suggested reason

resulting in the RACFs potentially being underserviced, and resultant inequity of

palliative care service provision and access across Gippsland.

Delays in admission to community palliative care services can cause barriers to access.

Poor and incomplete discharge planning from inpatient services to facilitate community

palliative care access in a timely manner potentially impacts on the patient being able to

die at home if that is their choice.

It was noted that clients who were already under a community palliative care service

and had required inpatient admission had a more streamlined discharge from inpatient

back to community suggesting that early referral and gathering of information may

facilitate a more streamlined transition.

Discharge from metropolitan hospital to Gippsland palliative care services appeared to

be problematic at times due to lack of understanding of the geography, accessibility of

particular services, and the capability and availability of palliative care service provision

in the region. The establishment of the GRPCCS has assisted by supporting the initial and

ongoing care of more complex patients returning from tertiary and metropolitan centres

to the region.

8.1.4 Provision of palliative care services Although the survey respondents identified short waiting times of palliative care

services, a snapshot of intake (see Appendix F) identified that dependent on the day,

service, staffing and client load, there indeed may be a lag time for admission to the

service, even if the referral is communicated as ‘urgent’. Some clients are being refused

palliative care as they live too far away, there is inadequate referral information

received, and early referral to palliative care is not a reality in some services due to

funding and resource issues.


17 | P a g e

After-hours support is provided by the community palliative care services through a

variety of models including use of the after-hours telephone triage tool by hospital

coordinators, home visits by nurses and some GPs, and telephone support.

The GPCCS provides a 24 hour telephone consultancy palliative care for afterhours

support for medicos or NPs only; they require a clinician after hours to be able to

prescribe if recommended and required.

Lack of a common electronic medical record to share patient information, at this stage,

continues to be a gap and risk for palliative care provision, particularly after hours.

There is a diversity of record management systems in health services impacting on

consistent and clear communication and data management.

Some GPs do not provide after hour visits or home visits.

Some GPs do not visit RACFs.

There is inconsistent understanding of the palliative care services responsibility to

provide service to clients in their homes including clients in RACFs.

Only one service utilizes telehealth for patient consults, however the distances to be

covered by clinicians, particularly the consultancy service, remain a major gap in

accessing palliative care.

All hospitals in Gippsland have adopted the Care Plan for the Dying Person to guide

inpatient end of life care. Some community-based nurses have requested this be

adapted for terminal care in the community as well. RACFs are supported to utilise the

RACFs EOLC pathway within their facility, and are supported in education by the GRPCC

Palliative Aged Care Resource Nurse.

8.1.5 Workforce capacity Workforce capacity and service shortage is perceived across all stakeholders in all

disciplines, particularly medical palliative care consultants. Currently there is only one

palliative care medical consultant in Gippsland. Locum palliative care physicians are

sourced to fill medical specialist gaps and share the after-hours consultancy phone

support. There is a wide variation in the knowledge and skills regarding palliative care of

health practitioners including community pharmacy.

Lack of generalist as well as specialist routine psychosocial support for patients is

identified by health professionals as a gap. Whilst the nursing and medical model has

solidified over the years, the gap in psychosocial and spiritual care and bereavement

care across all settings is a glaring omission compared to metropolitan services. There

appears to be a lack of interdisciplinary coordination and engagement. Despite this

some services are using flexible funding arrangements to meet the ongoing needs of the

clients and carers. Interestingly, survey respondents overall from community palliative

care and health services state they provide good psychosocial support.

Currently there are no established palliative care outpatient clinics in Gippsland.

There are three Palliative Care Nurse Practitioners (NP) and one Palliative Care Nurse

Practitioner Candidate (NPC) in Gippsland; two NP and the NPC based at the GRPCSS and

one community based palliative NP. They all work closely with local health services and


18 | P a g e

GPs in the delivery of palliative care through the provision of expertise and building skills

and capacity of the local palliative care providers.

Community based palliative care services in Gippsland continue working toward the

establishment of the recommended GRPCC Model of Community of Palliative Care,

2016. This model establishes specialist palliative care clinicians providing assessment

and triage, working collaboratively with generalist nursing staff and the GRPCCS

consultancy staff to provide best care for clients.

Based on the work of Bass Coast and the Maternity Skills Matrix framework, the GRPCC

in close collaboration with Gippsland Regional Educators Group, Monash School of Rural

Health and designated palliative care services has undertaken a baseline audit of

individualized, self-assessed palliative care skill capability for community nurses. Analysis

of the results provided feedback on professional development opportunities and guides

the intervention to provide relevant, coordinated palliative care professional

development. Education will be targeted to identified gaps. Results will inform

managers of the self-perceived skill mix of their nursing teams and assist in capacity

building toward their model of care. The survey can be repeated post intervention to

measure a shift in knowledge, skills and capability. In the future, the project will expand

to include nurses across a range settings.

8.2 Gaps The pathway processes to palliative care services are varied across the region. No

uniform minimum dataset is consistently requested by palliative care services on referral

to ensure comprehensive handover of care of the client.

There appears to be an inconsistent approach to triage of the palliative care patients.

This is creating an increased risk of delays and inequity in access for admission to

palliative care service and service delivery for clients.

There appears to be some confusion in the understanding of the role and scope of

palliative care services for the generalist health professionals and care worker

environments, particularly in the area of non-malignant palliative care, chronic disease,

aged care and dementia. This knowledge deficit is also a factor for patient, carer,

community, and is perceived as a barrier to accessing timely palliative care and

understanding the service requirements and supports.

Lack of understanding and capacity to accept referrals to palliative care for clients with

advanced chronic disease and barriers related to funding and program restrictions.

Poorly coordinated effective discharge and transition planning from care environments

for clients including health service to health service, home to hospital, hospital to home,

aged care facility to hospital, tertiary to regional hospital.

There is a growing need for the availability of appropriate respite to support carers and

to enable patients to die at home if this is their preferred wish.


19 | P a g e

8.1 What can be changed now to promote consistency The Gippsland Palliative Care Consortium will continue to facilitate collaboration with all

stakeholders in order to build capacity of the palliative care workforce across Gippsland

and to reduce unwarranted variations in care.

Consistent agreed referral pathways with minimum information dataset for referral to

all palliative care services across the region including the consultancy service.

Implementation of a consistent criteria triage tool to guide urgent and timely admission

to palliative care services across the region using PCOC data set and SAS tools.

Consistent feedback to GPs to ensure communication is improved, inclusive and timely.

Clarification and streamlining of chronic disease management programs with palliative

care to ensure timely and appropriate referral to palliative care, and effective care

coordination.

Development of a clear communication strategy with all stakeholders including working

with other Palliative Care Consortiums, GPHN, Health Pathways project; GRPCC

Community of Practice; GP practices; community palliative care services, health services

and GRPCSS to ensure the successful implementation of the above points, work

collaboratively towards consistent approaches, avoid unnecessary duplication and

leverage on others’ learnings.

Support the further development of the NP program in Gippsland to build capacity for

the future and succession planning.

Scoping and further development of telehealth opportunities based on other regional

successes in different disciplines.

Increased inclusion of interdisciplinary care planning of priority populations including the

aboriginal health worker role for clients with chronic disease to reflect the diversity in

palliative care client requirements.

8.2 What can’t be changed now and why The possibility of increasing funding beyond current levels should not be relied upon as a

strategy in the short term.

Workforce capacity in the short term. Recruitment and retention of a skilled palliative

care specialist workforce remain an issue for Gippsland. Lack of critical mass of palliative

care medical, nursing and allied health specialists can impact on the attraction of

recruitment to the region and subsequent service sustainability. In some subregional

areas there is limited employment opportunities for new staff appointments from

outside the sub region due to existing long term employment in positions and lack of

subregional opportunities for these appointments to take on new positions.

Conclusion

We can conclude from the survey data, from additional reports, and confirmed by face to face

phone consultation with stakeholders, that the primary issues in access and provision of palliative

care in Gippsland are: lack of a consistent minimum information data set provided to palliative


20 | P a g e

care services on referral; inconsistent triage criteria of palliative care patients; and lack of

comprehensive understanding of the scope of the palliative care service capability by generalist

health professionals and the community.

The need for greater access and knowledge of available carer and respite models remains an issue,

particularly with the non-malignant chronic disease palliative care patients and the younger

patient cohorts.

As the consultancy service becomes more established, with further recruitment and retention of

medical nursing and allied health staff, the support to the regional workforce will continue to grow

and build local capacity. This can be augmented by building on the success of other telehealth

projects to enhance palliative care and overcome the tyranny of distance and remoteness within

the diversity of Gippsland.

Continual development of strong and evolving collaborations between palliative care stake

holders across the Gippsland region and working cohesively with other consortia, government

departments and peak bodies will allow Gippsland to address the existing and future challenges

using consistent systems and process to reduce unwarranted variations in palliative care.

Appendices

Appendix A – Staff Profile by Palliative Care Service, Discipline and EFT

Appendix B – Survey Responses

Appendix C - A Model for Community Palliative Care in Gippsland. Part 1 – Report

Appendix D- DHHS report Community Palliative Care Service Gaps 2017

Appendix E - Collaborative Palliative Approach Referral Pathways Project

Appendix F – “A snapshot of urgent referral to palliative care in Gippsland in January 2019”

Appendix G - Research article conducted in Gippsland, and published 2019


21 | P a g e

Appendix A – Staff Profile by Palliative Care Service, Discipline and EFT

Service

Discipline / EFT

Gippsland Regional

Palliative Care

Consultancy

Service

Latrobe

Community

Health District

Nursing Service

West Gippsland

Healthcare

Group District

Nursing Service

South

Gippsland

Palliative

Care Service

Gippsland

Lakes

Community

Health

Bairnsdale

Regional Health

Service

Community PC

Bass Coast Health

Community PC

Central Gippsland

Health Service

Community Palliative

Care

Yarram and District

Health Service

Manager

1.0 EFT 1.0 EFT 0.8 EFT 1.0 EFT 1.0 EFT 0.7 EFT 0.1 EFT

CNC 1.5 EFT 1.0 EFT 1.6 EFT 0.8 EFT 0.7 EFT

Admin Support 0.6 EFT 1.0 EFT 1.0 EFT 0.5 EFT 1.0 EFT 1.0 EFT

PC Physician 1.7 EFT

PC NP 2.0 EFT

PC NPC 1.0 EFT

CNS

3.1 EFT

2.0 EFT 0.84 EFT (PC Coord)

District Nurses 16.67 EFT 16.3 EFT 10.6 EFT 16 EFT

Social Worker 1.6 EFT 1.0 EFT 0.6 EFT 0.5 EFT

OT

0.5 EFT

Physiotherapist

Grief & B’ment Counsellor

Volunteer Coord

0.1 EFT

Pastoral Care

0.4 EFT

Recruiting 0.6 EFT admin, 1.0

PC Physician, 0.8

Social Worker

?? PC Nurse

Practitioner??

Junior

development

staff to study in

PC

GP Vaccancies According to the RWAV Website at the time of this report there were 32 GP vacancies in Gippsland


22 | P a g e

Appendix B – Survey Responses Table 1 – Palliative Care Services Survey Respondents – The Palliative Care Services survey generated 8 responses:

Stakeholder group Number of response

Info about group

Community Palliative Care Services

7 8 Community Palliative Care services in Gippsland and we heard from 7 of these

Palliative Care Consultancy 1 1 Consultancy service in Gippsland and information was gathered from this service

Table 2 – Palliative Care Generalist Workforce in Healthcare respondents – The Generalist Workforce in Healthcare survey generated 302 responses

Stakeholder group Number of response

% of responses (/302)

Info about group

Allied health professionals 21 7% Occupational therapists (24%), speech therapists (14%), managers (10%) and exercise physiologist, physiotherapist and allied health assistant (5%)

RACF 13 4% Managers, care coordinators. 57% worked in a private facility and 29% a public facility.

Disability support workers 8 3% 38% private sector and 38% public sector

Case managers 9 3% Case managers included HARP care coordinators 44%, home care package providers (22%) and residential in reach, post-acute care and cancer care nurse (11%).

GPs 24 8% GPs included visiting medical officers (38%) and international graduates and locums (13%). 75% indicated that they have practiced for greater than 4 years and 54% worked full time.

Medical Specialists 4 1% Oncology (25%), public/private sector in general medicine/palliative care (25%), anaesthetics/pain relief (25%) and public system in a regional centre (25%).

Nurses 192 64% 44% of the nurses had been practicing more than 25 years, 45% were registered nurses and 42% were employed fulltime. 27% worked in district nursing/community nursing, 23% in residential aged care and 17% in acute.

Health Executives 2 0.5% From a sub-regional health service (50%) and residential aged care (50%) and peak body/organisation respondents both represented a primary health network.

Aboriginal Health Workers 5 2 %

Peak Body/Organisation 2 0.5% Respondents were from a primary health network

Other 22 7% Personal care workers (18%) and administration (9%). The majority worked in aged care (23%), small rural health (18%) service and a regional health service (18%).

Total 302 100%

23 | P a g e

Appendix C

A Model for Community Palliative Care in Gippsland. Part 1 – Report 2015

The Gippsland Regional Palliative Care Consortium (GRPCC) commissioned this project to

help community palliative care services meet the challenge of increasing demand. The

purpose of the project is to support capacity building through the development of a model

that may be adopted by services region-wide and is based on the national standards1. It is

intended that the model be adapted for local environments.

The main findings were:

district nurses (DNs) and general practitioners (GPs) have historically been

responsible for the palliative and end-of-life care of clients at home;

in recent years the core teams of DNs and GPs have been augmented by a nurse

practitioner (NP), nurse practitioner candidates (NPCs), palliative medicine specialists

(specialists), volunteers and allied health (AH) professionals;

the standard of palliative care has significantly improved and there is a great

commitment to learning and improving outcomes for clients;

some services are participating in the Palliative Care Outcomes Collaboration

(PCOC) and the National Standards Assessment Program (NSAP) but lack of

electronic support prevents benchmarking;

many DNs have undertaken short courses in the palliative approach but few have post

graduate qualifications in palliative care;

a range of AH practitioners is available but their full potential in palliative care is

not being realised;

multidisciplinary care is generally not well integrated; and innovative initiatives are not widely recognised.

This report is linked with the model and includes recommendations to:

optimise current resources; support DNs to achieve post graduate qualifications to achieve a critical mass of

specialist expertise;

appoint a DN to liaise between community and inpatient settings and actively

develop relationships within the multidisciplinary (MDT) team to promote seamless

and holistic care;

integrate client notes and care plans; ensure robust collection and reporting of data; and publicise innovation and expertise.

24 | P a g e

Appendix D- DHHS report Community Palliative Care Service Gaps 2017

Anecdotal feedback from discussion at the GRPCC Clinical Manager Group included the following

information:

‘There are many variations across the region regarding access and provision of palliative care

services of both inpatients and outpatients. What maybe an issue regarding palliative care

availability (both Inpatient and community) in one subregion may not be the same issue for

another so therefore hard to quantify as a region. An example is that one small health

service with a strong community palliative care service may not use all their inpatient bed

days but they maybe overspent in Community palliative care. This seems like it is not

following the patients’ needs/requirement and looking at palliative care across all settings as

a ‘package’ for the patients as required.

There is not ability to use the funding across community and acute so therefore may not

follow the patients. There may be a need in one area and not the other so hard to put a $

value on palliative care.

The regional hospital has 4 virtual palliative care beds that they flex up and flex down as

required. At present due to structural redevelopments they have 2 (physically) dedicated

beds they are using (rather than the 4 virtual) and the anecdotal feel is that this provides a

better experience for the patients, family and staff, however this model is not supported

when the palliative care funding is rolled up with the subacute funding.

The discussion raised that the funded services that provide inpatient and community

palliative care shouldn’t be a separate funding stream with dedicated bed days.

One community palliative care service has 4.3 EFT and a waiting list for community palliative

care.

We also have the unfunded services and small bush nursing centres who provide palliative

care to their community but are not funded at all so have to provide those $ from their

other funding sources.

The likely key initiatives required for the region were:

Nurse Practitioner support and training;

After hours development;

Building capacity and strengthening both specialist and generalist palliative care in both

inpatients and community settings;

Lack of respite options;

Community engagement including volunteer coordination;

Support for the implementation, evaluation and monitoring for Care of the Dying Person

Pathway.

25 | P a g e

Appendix E

Collaborative Palliative Approach Referral Pathways Project

In 2016, the GRPCC gave RACF in Gippsland the opportunity to be involved in a deceased resident

file audit, to evaluate the impact and effectiveness of the implementation of the palliative approach

key processes. For those who participated in the audit, it revealed that although, in some facilities

the palliative approach key processes were embedded, minimal referrals to specialist palliative care

for residents with complex or poorly managed symptoms was apparent.

In 2017-18, the GRPCC partnered with the Gippsland Primary Health Care Network (GPHN) in a

project to improve access for people with complex palliative care needs residing in RACF, to

specialist palliative care services. In collaboration with the RACFs and local palliative care services,

referral processes from RACF to palliative care services were mapped in each of the local

government areas (LGA) ; West Gippsland, Latrobe, Central Gippsland, East Gippsland, South

Gippsland, and Bass Coast.

Working parties were formed in each LGA and key stakeholders were invited to work collaboratively

to form a palliative care referral pathway that utilised local resources and health service structure to

formalise or initiate referral processes from RACF to specialist palliative care for clients with complex

or unmet palliative care needs.

Due to variations in resources, health service structure, and operating procedures, each LGA

documented a different pathway of referral from RACF to specialist palliative care services via the

local palliative care service.

The use of collaborative forums in each LGA facilitated the introduction of the pathways to RACF

management and leadership. All RACFs, local medical practices, Palliative Care Services and

Residential In Reach Services have been provided with copies of the referral pathway for their

specific region.

26 | P a g e

Appendix F – “ A snapshot of urgent referral to palliative care in Gippsland in January 2019”

Information related to the ‘snap shot referral activity’ completed on Jan 21& 22, 2019

Palliative Care Services were all asked the following questions relating to: “I want to refer a patient for palliative care- this is an urgent referral”

1. What information do I need to supply?

2. How do I provide this information (form, template)?

3. How is the ‘urgency’ of this request assessed? By whom? Triage tool?

4. What is the usual response time to an ‘urgent’ referral

5. How does the GP get feedback on the referral (ie, referral accepted and client care commenced)?

6. Any other info that came out of this discussion

PCS Intake person Info needed Info provision Triage Urgency Usual response time

GP feedback

Any other info

1 Intake RN- for PC and DN assessment by PC Team leaders

Conversation with GP ? needs to be in hosp

GRPCC referral form or CMA

By PC Team Leader- no proforma

24-48hrs No formal process

On this day, due to staffing, would not be able to see within 48/24

2 Intake RN- for PC and DN

Conversation with GP /then with client/carer (Dx, Prognosis, tests, scans, active Tx?, what care can GP offer,

HS specific form Or SCTT tool

By intake, based on over phone assessment using PCOC- no proforma

If urgent, 24/24 (if symptomatic), M to F

By fax Need to have confirmation that the person was “palliative”, not having “active treatment”

3 Intake RN-PC MHx, Date of Dx, tests, scans, Meds, PCOC, key symptoms

Region Specific Palliative Care Referral form

Region Specific Triage form- stable/ local/ phase of care, pain/complexity/opioid naïve. 3/12 prognosis

A- Within 24/24 B- 2-5 days C- 6-10 days

Phone/fax. Meeting 2/52 with GPs

Is the person having active Tx or Palliative Tx

27 | P a g e

PCS Intake person Info needed Info provision Triage Urgency Usual response time

GP feedback Any other info

4 Admin intake, service access desk, onto system, and then allocated to PC CNC (in tray)

Health record/summary, tests Phone assessment or F2F

S2S, fax, No formal process- triaged by CNC/PC coord.

If assessed as urgent, within 24/24

No formal process

6 RN PC intake Phone conversation with GP “what makes it urgent”, and with client/carer to assess ‘urgency”

Health summary, CMA,

By PC. Based on reason for referral, ?pain crisis,

If assessed as urgent, within 24/24

Template letter to GP (GRPCC), emergency meds, dr specific orders/plans

7 Admin intake Dx, General Health summary, CMA, relevant tests, scans/bloods- admin make contact with client/carer and access info from GP

Fax from GP- info and letter

NUM DN/PC would triage referral, and refer on to NP, psycho social support if needed

24/24, but in reality, not able to meet this time frame. If ‘urgent’, ? admitted to hosp.

No formal process

8 RN PC intake PC needs, scans, path, relevant documents

Cover letter from GP with reason for referral, S2S from regional hosp

GRPCCS doc Within 24/24 Write letters to GP. GP MDT 2/52 ( PCS go to GP practice)

9 RN PC intake Tests, Dx, med Hx, info relating to ‘urgent status’.

Fax, SCTT Small community. terminal care- on call arrangements made

24/24 Not formal GPs like PC to go on home visits with them

Pathways to specialist palliative care in rural regions – Gippsland Region

28 | Page

Appendix G

Khalil, H., Poon, P., Byrne, A and Ristevski, E. (In Press) Challenges associated with anticipatory

medications in rural and remote settings. Journal of Palliative Medicine.

Challenges associated with anticipatory medications in rural and remote settings Background Anticipatory medications (AM) have been widely used in various settings across many countries in people approaching end of life. Palliative care in rural and remote areas of Australia is lacking as are other medical services when compared to the metropolitan setting. Our aim is to identify challenges with the administration and access to anticipatory medications in rural and remote communities with outcomes to guide improved delivery of care. Method An online survey administered using Qualtrics, a secure survey platform was distributed Invitations to a total of 18 managers from 18 rural and remote organisations across the South East of Victoria in Australia. The survey was distributed to a total of 108 nurses working in these organisations. Results A total of 29 nurses completed the survey (response rate 28%). Most of the nurses were working in a mixed practice providing community palliative and district nursing. A significant number of nurses (n=9, 31%) were working in remote settings and the remainder were located in regional areas. Almost a third of all nurses surveyed did not have specific guidance regarding the use of anticipatory medications for their patients. Opioids (55%) were by far the most commonly used anticipatory medications followed by anti-emetics (45%). The most common decisions taken by nurses to administer anticipatory medications were cited as patient deterioration or in their terminal phase and fluctuating level of anxiety and agitation of patients and/or their carers. Access to AM and lack of staff education were major challenge in rural and remote areas. Conclusion Provision of timely AM has the potential to improve the quality of life of patients and their carers’. Key barriers to access AM can be overcome with community level planning and nurses’ education. Advanced nurses’ roles have the opportunity to provide specialised care where access to specialists’ physicians is challenging.

pathways to palliative care in rural victoria · the nurse practitioner (np) program is well...

Documents