Palliative care and GP teams – defining the optimum Peter Woolford Simon Allan

Scallop season opens this weekend!!!

Place of death over 3 hospices Die at home36%56%52% Die in hospital 10%12%22% Die in hospice 37%7%14% Die in residential care 17%25%12%

GPs are integral to providing best care GPs are widely regarded, in all developed countries, as being pivotal to successful, high quality cost-effective home based and community care.

GPs are integral to providing best care They provide contextural knowledge of a patient, family dynamics, history of illness, routine medical surveillance, early intervention to prevent or control symptoms, medical care of carers and bereavement surveillance of carers. Mitchell 2004.

Both Programmes ultimate goals “To support the terminally ill patients who choose to die at home, and to support the GPs to deliver generalist palliative care who are able to support this option”

Aims PC1 To fulfil the expressed wish of patients who have a stated preference to die at home PC2 To deliver coordinated primary care to support patients their families/whanau through the end of life experience

Access to hospice beds PC1 Limited, none in the immediate vicinity. Available on a limited basis across town PC2 Access available locally and reasonably easily

Number of practices enrolled in the programme PC1 21 of the 25 eligible practices 84% PC2 11 of the 19 eligible practices 58%

Number of GPs involved PC1 36 of an eligible % PC2 21 of an eligible 71 30%

Patients enrolled in the study year PC1 114 PC2 110

Age of patients enrolled PC1 Range 24 – 94 Mean 61 More cancer diagnoses – 93% PC2 Range 45 – 100 Mean 81 Less cancer diagnoses - 46%

Deaths PC1 Range of days in programme 1 – 275 Median (66%) patients died 55 (72%) died in their own home/residence 5 died in hospital PC2 Range of days in programme Median 30 days 9 (8%) patients died 2 (2%) died in their own home/residence

Services provided by GPs PC1 Practice visits – 108 Home visits – 304 Extended HV – 80 Total contacts PC2 Practice visits – 34 Home visits – 31 Initial visit with ACP – 110 After hours visits – 15 Total contacts - 190

What did the programmes have in common? Shared ultimate goals Quality GPs committed to providing good palliative care Strong education package for GPs Access to specialist advice Access to funding for patients. In PC1 this was primarily for home visits to dying patients, in PC2 there was a strong emphasis on completion of an ACP

How did the programmes differ? PC1 Used Irene Higginson’s POS. This was dropped early on as it became clear it was not transferable PC2 Used an Advance Care Plan, which remained a compulsory part of the programme

How did the programmes differ? PC1 Focused on care in the home and inevitably therefore the last 3 months of life. PC2 Focused on the ACP, and thus more non cancer patients were enrolled

How did the programmes differ? PC1 Has a GP taking an active part in the weekly multidisciplinary team meeting PC2 Has no regular GP involvement in the hospice

How did the programmes differ? PC1 Has a back up call system of 3 GPs, available for the patient’s regular GPs if they are unavailable PC2 Has a system relying on regular GPs, hospice nurses and palliative care specialists who do not visit

How did the programmes differ? PC1 Funding is focused on home visits PC2 Funding is (accidentally) focused on ACP

80% of patients being supported to die at home Spinoffs Fulfilling patient wishes Healthier for the patient Healthier for the patients’s family Healthier for communities Decreased acute and inpatient demand on hospitals

An integrated model of care GP involvement in hospice – MDT Hospice nurses always using the GP as first port of call for medical advice Hospice nurses carrying medication and being able to administer on GP advice PC specialist acting as consultants, particularly consulting in home with GP

An integrated model of care - 2 All team members being proactive using an anticipatory model of care. Palliative care lends itself to this Provide ongoing education in a variety of formats web based/short course/ordinary CME diploma/masters level (grants by PHO)

An integrated model of care - 3 GP’s being available 24/7 – No need for individual GP to be 100% available – Need to be flexible – May only need phone contact – May delegate to partner – Have a back up system of GP cover

An integrated model of care - 4 Pay patient fees for home visits Encourage/pay GPs for ACPs – Link in with national programme – Not compulsary

Integration across services Tuia te rangi e tu iho nei Tuia te papa e takoto nei. Join the sky above To the earth below Just as people join together As sky joins to earth, so people join together. People depend on one another