Palliative care service patients are frequently discharged alive. Scarce evidence exists about the patients who have multiple discharges from a community palliative care service.

 

To characterise patients who had multiple community palliative care episodes.

 

Patients alive at discharge from the Sacred Heart Community Palliative Care Team, Sydney, between 1 July 2010- 31 September 2018, were identified using local health records. Univariable and multivariable logistic regression analyses were used to identify patients’ characteristics associated with multiple palliative care episodes. 

Results:

1,095 out of 5,270 patients (20.7%) were discharged alive. Among those, the median number of palliative care episodes was 1 (interquartile range 1-2), with 454 patients (41.5%) discharged more than once (‘frequent users’).

 

At the first discharge, the median age was 77, with 575 (52.5%) female patients. Univariable analyses found frequent users were more likely to be living at their own residence (versus nursing home OR 2.18, 95% CI 1.59-3.03; versus no usual accommodation OR 3.33, 95% CI 2.33-5.0), living alone (versus living with others OR 1.61 95%CI 1.06-2.32), to have malignancy as the primary diagnosis versus non-malignant OR 2.40 95%CI 1.84-3.13) to have been referred by a palliative care service (versus specialist OR 1.56 95%CI 1.18-2.06). 

 

In multivariable analyses, adjusting for all patient characteristics simultaneously, the same factors were significantly associated with frequent services use.

In this study, characteristics such as a patient’s usual accommodation, whether they live alone, primary diagnosis, and referral source were independently associated with frequent community palliative care service users. Further research into why patients are frequent service users may assist in service delivery planning. 

Palliative Care Australia (PCA) has been producing specialist National Palliative Care Standards for over 15 years, with the objective to improve quality palliative care experiences and outcomes for people, their families, and carers.

The current suite of quality improvement resources developed by Palliative Care Australia (PCA) includes:

-          The National Palliative Care Standards 5th ed (2018) 

-          PaCSA –Palliative care self-assessment online portal

-          Palliative Care Service Development Guidelines (2018)
-          Paediatric Addendum: Palliative Care Service Development Guidelines (2019)

-          National Palliative Care Standards for All Health Professionals and Aged Care Services (for those not working in specialist palliative care) (2022)

The speaker will introduce through the suite of quality review and improvement tools available to services under this suite of resource and examples of how these are used for quality improvement in practice.  They will also discuss the two-phase consultation process for the limited scope review of the National Palliative Care Standards 5th ed. (2018) for specialist palliative care services and next steps for the Standards in specialist palliative care.

Background

The Northern Beaches Community Palliative Care Service (NBCPCS) provides a multidisciplinary consultative community palliative care service to a population of over 266,000 people on the Northern Beaches of Sydney. This occurs through clinics and home visits, including to RACF.

Aim

Our challenge has been in managing large patient numbers (approximately 350), whilst aiming to improve patient and family outcomes. The team strongly felt that more proactive strategies were required to recognise deterioration and intervene earlier. Further aims were to improve symptom management, and timeliness of goals of care discussions and planning.

Strategy

A three-pronged approach to redesigning patient management was developed. 
1. A  clinic model for mobile patients was established to facilitate efficient input from multiple members of the MDT in a single visit.
2. A  robust, proactive caseload management strategy was developed using a nurse-led model, with clear expectations for patient monitoring and follow-up. 
3. In order to improve our service’s responsiveness and to recognise deterioration earlier, the Palliative Care Outcomes Collaboration (PCOC) was embedded as a central part of handovers and multidisciplinary team (MDT) meetings. The aim was to more proactively track patients in the unstable, deteriorating and terminal phases.

Outcomes

The three-pronged strategy has now been established and is collecting data. By improving responsiveness and delivering proactive care, we aim to show a reduction in out of hours phone calls and acute hospital admissions, and an improvement in PCOC benchmark reports. An initial reduction in after hours calls has already been observed, and interdisciplinary and cross-team collaboration has improved. Staff will complete a survey to ensure feedback from the MDT is captured.

Conclusion

The NBCPCS has developed proactive strategies to improve patient and family outcomes, as well as collaborative care within our team. We believe that our strategies can be replicated in other community palliative care services to improve patient care.

Background Early palliative care (PC) has been shown to improve outcomes for patients with advanced haematological cancer including Multiple Myeloma (MM). ‘Care Plus’ is a stepped wedge implementation trial testing usual care (control) versus early PC integration as practice change across cancer services at four Australian metropolitan tertiary public hospitals.  

Aims To describe the utility of the Care Plus pathway implementation strategies in integrating PC with haematology oncology services including MM. 

Methods This qualitative research study design was introduced at a standardised point(s) in the illness, either at the time of diagnosis or first relapse of MM. Semi-structured interviews with participants were conducted via Zoom or face-to-face during pre-practice, practice and post-practice change to explore the implementation strategies. Interview transcripts were thematically analysed by making codes with emerging themes via NVivo. Member-checking was utilised for maintaining rigour and validity. 

Results Care Plus team conducted 20 interviews with haematologists (n=4), PC physicians (n=9), clinical nurses (n=3), MM patients (n=4), and MM nurse care coordinators (n=4). Major themes for strategies included: benefits of automatic standardised points for referral to early PC as a system wide change, development of language as ‘Care Plus’ plus scripts for introducing early PC by health personnel to patients and carers, PC presence in multidisciplinary meetings, enhanced collaborative practice between haematology and PC teams, and the value of exploring future goals and planning with early PC including asymptomatic patients. 

Conclusions Care Plus implementation strategies provided a systemic approach to integrating PC with MM oncology services. For haematology clinicians, the Care Plus model appeared to provide an opportunity to ‘re-imagine’ how PC may be delivered and the role it plays in patient care.  

In Australia, there has been an effort from the government over the past decade to improve equity and inclusion in palliative care. Policy context supportive of equity acts as a critical driver for enabling its translation into equity-oriented practice. However, the extent to which Australian palliative care policies incorporate equity, and their translation into actions and investments has not been extensively examined.

 

To explore policy approaches that supports equity and inclusion:

o   Ways in which equity is defined

o   The extent to which recommended strategies and actions are equity oriented

Methods 

We analysed 6 national and 22 jurisdictional palliative care policies, strategic plans and evaluation reports that are publicly available. The policy review was informed by an equity action framework. Inductive and deductive thematic analysis was used to identify key themes.

Findings
A shift of focus in considering equity in Australian palliative care policy was evident in documents.  Palliative care policies acknowledge and recognise the significant variation in access to palliative care services.  Strategies across jurisdictions have broadly focused on utilising a blended approach of ‘Targeted Universalism’ to improve palliative care services for all while identifying obstacles faced by specific underserved groups. Intersectoral collaboration is acknowledged explicitly or implicitly in policy documents.  However, collaboration was mainly seen as vertical collaboration (within health services) with minimal evidence of proposed or actual collaboration with sectors outside health. Compassionate communities’ approach to engage and empower communities is recognised in policy documents. However, the role of government in leading a public health approach to palliative care is not clear.

Achieving the goal of equity in palliative care for all is complex and multifaceted. It requires strong commitment and actions at policy and government level but also in clinical practice, workforce planning and capacity building, community engagement and research investment.

Background: Collaboration between palliative care units (PCUs) and community palliative care (CPC) services is key to providing integrated care across inpatient and outpatient settings, in response to local and global challenges.

Aim: To identify the effect of the COVID-19 pandemic and local CPC service changes on the characteristics of patient admissions, discharges, and access to a specialist PCU in Sydney, Australia.

Methods: A retrospective cohort study of PCU admissions was performed across three six-month periods, in 2017, 2019 and 2021. The association between patients’ principal diagnoses and CPC service involvement prior to their first PCU admission was analysed. Admission characteristics including referral source, length of stay, palliative care phase and place of death were compared between the three time periods. 

Results: There were 707 admissions during the studied time periods, corresponding to 589 unique patients, of whom 89% had a principal diagnosis of malignancy. Non-cancer patients had half the odds of being linked to a CPC service compared to cancer patients on admission (OR = 0.48), and haematology patients a third of the odds compared to other patients (OR = 0.34). Most admissions (51%) were arranged to the PCU directly from the community. Compared to earlier time periods, during the COVID-19 pandemic peak in 2021, patients had shorter admissions (5 vs 8 days; p <0.001), were more likely to be discharged in the deteriorating or terminal phases (p <0.001), and had four times the odds of dying at home (OR = 4.11).

Conclusions: COVID-19 has had significant impacts on PCU admissions and patients’ preferred location of care, which has implications for the development of sustainable models of care to meet the increasing demands on CPC services. Continuous service delivery evaluation and adaptation is required to ensure equitable access to palliative care for all patients, especially during periods of change.