wodonga palliative care service jenny sutter, stacey heer, leanne hills
TRANSCRIPT
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Wodonga Palliative Care Service
Jenny Sutter, Stacey Heer, Leanne Hills
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First, Some Background
• Increasing demand on palliative care service
• Increasing demand for coordinated care
• Increasing need for patients to manage
own health care
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Our Service
• Health information not being exchanged
• Patients struggling to maintain autonomy
• Patient satisfaction surveys – carers want
more support
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Project Aims…….
Improve Coordination of Care and Communication
Improve Patient Control in Own Care and Decision Making
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Methodology
• Communication Tool – patient diary
• Adaption versus development
• Mid North Palliative Care Referral and
Planning Project – patient diary
• Challenge – adapt to suit our community
based service
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Trial Distribution Criteria
• Capacity • Ongoing palliative care• Not in a residential facility• Not terminal or rapidly
deteriorating
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The Modern Health Care System
• Care occurs increasingly in home
• Treatments more complex
• Numerous health care providers
• Increased need for patients to self care
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Provide Accurate Medical History
and Medication History
Modern Health Care requires patients to . . . . .
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Communication Barriers For Patients
•Poor Health Literacy•Language Barriers•Cognitive and Thinking issues •Affects of disease and treatment
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Communication Effects: Patients
•Don’t understand or follow treatment•Miss appointments•Take medications incorrectly•Low continuity of care: low patient satisfaction•More complaints
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Communication Effects: Health Care Worker
•Unnecessary tests•Unaware of all health care providers•Double up on referrals•Low continuity of care •Medical errors
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Better Continuity of Care
Fewer hospitalisations
Fewer emergency department presentations
Lower repetition demands on patient
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Patient Held Records……Better Communication
Patient needs more likely to be metHigher patient autonomyLess burden on health care workersEnd of life choices met better
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and financial
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Diary includes
• Enduring power of attorney
(medical / financial)
• End of Life Directive Contact
• End of Life Wishes
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This is special place where you can think about and perhaps write some notes on what is important to you, regarding your care at the end of life.
For example:
“It is important to me to stay at home for as long as possible”
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Changes from review:
Pain chart
Extra plastic sleeve for reports
Extra test results pages
Removable calendar at back
Name change to Care Diary
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FeedbackMost helpful sections: medication, appointments, glossary
Everything in one place & easy to use
Few took diary to specialists
Approximately half took to hospital
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Carer Feedback
• Improved communication between health professionals and family
•Felt more in control of care
•Comments by professionals were positive
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Ongoing Issues for the Care Diary
$ Cost $
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No communication tool is perfect…..
Keeping the diary up to date Future reviews
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applicable for all….
The care diary is not
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Acceptance by
Health Care Providers
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Thank you, questions, questions…….