1. Gold Coast Health Service District Introduction to Palliative Care Services Ingrid Skilton – Clinical Nurse Consultant Katherine O’Shea – Senior Occupational Therapist

2. Introduction Palliative Care provides coordinated care across hospital and community for patients with a terminal illness. Palliative Care provides coordinated care across hospital and community for patients with a terminal illness. The main aim of Palliative Care is to maximise the quality of life and provide comfort and dignity throughout the life- limiting disease process. The main aim of Palliative Care is to maximise the quality of life and provide comfort and dignity throughout the life- limiting disease process. Palliative Care consists of a multidisciplinary approach. Palliative Care consists of a multidisciplinary approach.

3. It is well researched and documented that most people would prefer to die at home (Wilkes & Beale, 2001). Currently Registered with GCH Palliative Care Services there are approximately 400 Palliative Patients all linked with NGO Service Providers.

4. GCHSD Palliative Care Services 1. Gold Coast Hospital - Southport Campus - Robina Campus - Carrara 2. Palliative Care Inpatient Ward - 20 Beds- Currently at Pacific Private (likely to move back to Robina Hospital in January 2011) 3. Community - Patient’s Homes - Residential Aged Care Facilities - Interim Care Facilities - Hospice - Private Hospitals

5. Where Do We Get Referrals From? Referrals must be from a doctor for patients to be registered with the palliative care serviceReferrals must be from a doctor for patients to be registered with the palliative care service A referral letter to our medical team or GPGC referral template is acceptableA referral letter to our medical team or GPGC referral template is acceptable Fax/email details:Fax/email details: gchpalliativecare@health.qld.gov.au gchpalliativecare@health.qld.gov.au gchpalliativecare@health.qld.gov.au 5668 3905 5668 3905

6. Consultancy Team Team makeup: Team makeup: Dr Barbara Craig + RegistrarDr Barbara Craig + Registrar Clinical Liaison NurseClinical Liaison Nurse Role Role Inpatient assessment, review + discharge planningInpatient assessment, review + discharge planning Symptom consultsSymptom consults

7. Inpatient Team Team makeup Team makeup Medical + nursing + allied healthMedical + nursing + allied health Team Role Team Role Symptom assessment and multidisciplinary treatmentSymptom assessment and multidisciplinary treatment Terminal CareTerminal Care Discharge planning and coordination with community team & NGOsDischarge planning and coordination with community team & NGOs

8. Community Team Team Makeup Team Makeup Medical Consult + Registrar +CNC partnership position + OT + SW + allied health project team + clinical liaison nurseMedical Consult + Registrar +CNC partnership position + OT + SW + allied health project team + clinical liaison nurse Team Role: Team Role: Home visitsHome visits Symptom management at homeSymptom management at home In partnership with NGOsIn partnership with NGOs Patient choice of care/future care planningPatient choice of care/future care planning Supporting patients’ choice of care settingSupporting patients’ choice of care setting

9. Allied Health Supportive Care Initiative Funded until June 30 2011 Funded until June 30 2011 PhysiotherapistPhysiotherapist Occupational TherapistOccupational Therapist Social WorkerSocial Worker DietitianDietitian Speech PathologistSpeech Pathologist Therapy AssistantTherapy Assistant (all part time – various FTE (approx 2-3 days/wk)) Demonstration project exploring a new model of care Demonstration project exploring a new model of care

10. Goals of the Allied Health Supportive Care Initiative Primary role is to facilitate Advance Care Planning (including facilitating discussions around future plans and develop care plans, Advanced Health Directives, EPOA, etc.) Primary role is to facilitate Advance Care Planning (including facilitating discussions around future plans and develop care plans, Advanced Health Directives, EPOA, etc.) Aim to prevent ‘crisis admissions’ to hospital, through combination of future planning, as well as MDT AH input. Aim to prevent ‘crisis admissions’ to hospital, through combination of future planning, as well as MDT AH input. Accepts clients with AKPS>=60, RUG- ADL>11, Phase 1 or 2 for an 8 week multidisciplinary treatment period. Accepts clients with AKPS>=60, RUG- ADL>11, Phase 1 or 2 for an 8 week multidisciplinary treatment period. If people require ongoing therapy, will facilitate referral to community services for ongoing care. If people require ongoing therapy, will facilitate referral to community services for ongoing care.

11. Palliative Care Partnership Position In 2009 Qld Health along with NGO stakeholders Ozcare, Bluecare and Spiritus secured funding for a Community Palliative Care CNC position funded through General Practice Gold Coast and was to be filled by a current employee of one of the auspicing NGO stakeholders. The position was to increase partnership and improve patient flow across all care settings. Initially this position was funded for 18 months and then is to be readvertised amongst all NGO staff and if appropriate rotated between agencies.

12. The Community CNC Position aims to continually evaluate and improve: Weekly community case conferences. Weekly community case conferences. Build and maintain strong links with all NGO providers across the Gold Coast Health Service District. Build and maintain strong links with all NGO providers across the Gold Coast Health Service District. Use of evidence based palliative care tools across the District. Use of evidence based palliative care tools across the District. Aim to increase number of Palliative Care patients with an advance care plan. Aim to increase number of Palliative Care patients with an advance care plan. Aim to decrease Emergency Department presentations of registered palliative patients. Aim to decrease Emergency Department presentations of registered palliative patients. Aim to decrease hospital admissions for registered palliative care patients. Aim to decrease hospital admissions for registered palliative care patients. Aim to increase satisfaction amongst patients, families and all stakeholders. Aim to increase satisfaction amongst patients, families and all stakeholders. Allow patient and families choices in regards to end of life care setting. Allow patient and families choices in regards to end of life care setting. Provide leadership across the District relating to holistic evidence based palliative care. Provide leadership across the District relating to holistic evidence based palliative care.

13. Community Referrals

14. Palliative Care Program Funding Funding EquipmentEquipment (large items (bed/pressure care/mobile commodes/etc, as assessed by Palliative OT re: functional needs of client) (large items (bed/pressure care/mobile commodes/etc, as assessed by Palliative OT re: functional needs of client) ConsumablesConsumables (following assessment and discussion between NGO and Palliative Care Service) (following assessment and discussion between NGO and Palliative Care Service) Funded nursing careFunded nursing care (as assessed by NGO) (as assessed by NGO)

15. Assessment Tools Used RUG-ADL RUG-ADL Bed mobility, eating, toileting and transfersBed mobility, eating, toileting and transfers AKPS AKPS Overall functional scaleOverall functional scale Phase Phase Point in disease trajectoryPoint in disease trajectory (stable/unstable/deteriorating/terminal/bereav ed)(stable/unstable/deteriorating/terminal/bereav ed)

16. The future of Palliative Care… Development of End of Life pathways across all inpatient facilities, residential care facilities and the community. Development of End of Life pathways across all inpatient facilities, residential care facilities and the community. Complete community palliative care liaison service interfacing with GP’s and NGO’s to provide best practise community palliative care. Complete community palliative care liaison service interfacing with GP’s and NGO’s to provide best practise community palliative care. Develop a range of resources and education packages to assist community staff with OT palliative care specific needs. Develop a range of resources and education packages to assist community staff with OT palliative care specific needs. Continue to build strong partnerships with community services. Continue to build strong partnerships with community services. Allied health project to continue Allied health project to continue

17. What can you do? Encourage referrals to the Palliative Care Service – it’s never too early or too late. Encourage referrals to the Palliative Care Service – it’s never too early or too late. Ask for advice from Palliative Care Services staff. Ask for advice from Palliative Care Services staff. Provide Contact details to patients and families when appropriate. Provide Contact details to patients and families when appropriate. Provide information to patients and families when appropriate. Provide information to patients and families when appropriate. Ask Palliative Care Services for further inservices, information, pamphlets. Ask Palliative Care Services for further inservices, information, pamphlets. Support Community networks by considering active membership to associations. Support Community networks by considering active membership to associations.

18. Contact the Palliative Care Service Business Hours – single contact point Ph: (07) 5668 3900 Fax:(07) 5668 3905 Palliative Care On-Call Consultant (24 hours) Ph: 55 198 211 Palliative Care On-Call Nurse (730-4pm) Ph: 0466 207 634 Palliative Inpatient Unit Contact (All Hours) Ph: (07) 5519 7501 Palliative Care Senior OT (business hours) Ph: 0416 085 662