Abstract
Short introduction/background: RPA Virtual Hospital, through its Sydney District Nursing Service, has been delivering community palliative care for many decades. Recent patient experience data indicates that 97.3 per cent of patients felt that care provided helped them stay in their own home and out of hospital or a residential aged care facility.
In 2021 the New South Wales Government announced a funding enhancement to strengthen palliative care, with a mandate to support strong, integrated, and effective responses for people with late-stage chronic disease to maintain wellbeing and independence at home. RPA Virtual Hospital established a new community-based Chronic Disease Palliative Care Team. The model of care utilises existing structures, processes, and care models through the Virtual Care Centre and Sydney District Nursing to provide care to this cohort of patients.
Why did you do it? To address the gap in RPA Virtual Hospital community palliative care services for people with late-stage degenerative and chronic conditions and disability, by providing multidisciplinary clinical services with a strong Allied Health focus.
Who is it for? The Service is for palliative care patients with late stage degenerative and chronic disease and aims to enhance quality of life and provide support for patients to remain at home for as long as possible. Reducing unnecessary Emergency Department presentations and avoidable hospital admission and face-to-face outpatient consultations. Supporting General Practice with the management of these patients.
Who did you involve and engage with? Guided by the NSW Ministry of Health guidelines for funding, the initial proposal involved consultation with Sydney District Nursing Senior palliative care staff, RPA Virtual Hospital and Allied Health Executive.
The Palliative Care Chronic Disease multidisciplinary team includes the following dedicated positions, Palliative Care Clinical Nurse Consultant, Speech Pathologist, Dietician, Clinical Psychologist, Occupational Therapist, Physiotherapist, and a Senior Aboriginal Health Worker.
Monitoring of the program is facilitated through weekly MDT (Multi-Disciplinary Team) and regular data collection and review, including direct patient feedback.
What did you do? Once successful in achieving the funding, Allied Health and Nursing Consult positions were recruited to and commenced providing additional services to Sydney District Nursing Palliative Care patients with a chronic disease as their primary diagnosis.
What results did you get? What impact did you have? Gaps in service for late-stage degenerative and chronic conditions and disabled patients were filled with access to allied health professionals. Patient experience of receiving the Allied Health services has been extremely positive – many patients had not previously been able to access speech pathology, dietetics, or psychology in the community. Patients have had improved outcomes from receiving interventions specially designed for their disease group.
What is the learning for the international audience? Integrated chronic care, provides real benefits to palliative care chronic care patients and their families, when additional allied health and nursing consultation services are provided in the home.
What are the next steps? Communication and promotion of service. Development of research projects looking at the impact of allied health in end-of-life care for palliative care chronic disease patients.