Transcript Slide 1

PALLIATIVE CARE
Why?
Australian College of Nursing
Victorian Chapter
7 February 2013
Helen Walker
Cabrini Palliative Care
•Current Scene
•Clinical Outcomes
•Economic Advantages
•Role of Health Funds
•Future Trends
PALLIATIVE CARE
•
Aims to optimise quality of life of patients and
their families facing a life limiting illness.
• It can be offered at anytime after a diagnosis
and integrated into the overall treatment plan.
• The palliative approach needs to be practiced
by all health care practitioners with assistance
from specialist services as required.
CHANGING DEMOGRAPHICS
•Australia has an ageing population
•Increased life expectancy
•Decreasing fertility rates
• % over 65s increasing
•Over 85 aged group growing
– increased health care needs
•International trend
•‘Sea change’ phenomena
•Cultural diversity
•Older age of carers
AGING POPULATION
Both the number of deaths and proportion of people aged
65 or over will dramatically increase in upcoming decades.
They project:
• 1:4 of the population will be aged 65 or older as opposed
to 1:8 in 2009.
• Pattern of disease changing - to include complex chronic
illness in a higher proportion of the population.
• An increasing focus on palliative care service provision.
(AIHW 2011)
PROJECTED DEATHS
Insured persons by age cohort
Female
90–94
Male
Age Category
80–84
70–74
60–64
50–54
40–44
30–34
20–24
10–14
0–4
450
300
150
0
Insured Persons ('000)
150
300
450
Current service issues
Australia is faced with an ageing population and therefore an
increasing prevalence of age-related chronic conditions, such
as cancer, organ failure, and dementia, which may require
palliative care.
(Australian Bureau of Statistics, 2009).
Current Service Levels
Each year in Australia, approximately 134,000 die
and approximately half of these deaths are
classified as expected, suggesting a large demand
for palliative care services.
(CareSearch-Palliative Care Knowledge Network, 2012;
Gordon, Eager, Currow, & Green, 2009)
DEATH TRAJECTORIES
Understanding what happens at
end of life, helps us to plan,
involve patients and families,
support and provide best care.
Sudden death vs Cancer vs Chronic
Illness vs Frail Aged
Sudden death
Time course to death
Sudden death vs Cancer vs Chronic
Illness vs Frail Aged
Sudden death
Cancer
Time course to death
Sudden death vs Cancer vs Chronic
Illness vs Frail Aged
Sudden death
Chronic illness
Time course to death
Sudden death vs Cancer vs Chronic
Illness vs Frail Aged
Sudden death
Time course to death
Models of Palliative Care in Australia
Palliative care is provided by public, non-government and private
organisations, through a combination of delivery models, including:
• Designated hospice services
• Designated palliative care units in acute and sub acute hospitals
• Non-designated inpatient palliative care services in acute or sub
acute hospitals
• Ambulatory palliative care hospital services
• Specialist palliative care community services
• Primary care community-based services
(Gordon, et al., 2009)
Models of Palliative Care in Australia
By international standards, Australia has been described as
having impressive palliative care coverage of 85% of the
population, delivered through flexible models of care across
inpatient, outpatient and home settings.
(Gomes, Harding, Foley, & Higginson, 2009)
Palliative Care Services in the Australian
Private Sector
Privately insured patients:
• Have an expectation their insurance will cover them
through all aspects of their illness journey and not cease
when curative treatment is no longer appropriate.
• Are unable to access palliative care - therefore receiving
more expensive, and at times, aggressive treatment in the
final stages of life in a private acute hospital, which may
not be the best place of care on many fronts.
Preferred place of death – need to invest
•
•
•
•
•
Most people want to die at home
Many don't get this opportunity
Many reasons – many with a solution
Deaths in acute facilities are often problematic
We need to invest in community support to address
this problem – cheaper than ICU
Models of Palliative Care in Australia
However, more progress is required, with regard to
the establishment of flexible funding and financing
models to improve integration of care and
encourage service substitution across settings.
(Gordon, et al., 2009)
Strategic Frameworks
Australian Government and States and Territories have
developed over arching strategic frameworks to guide the
formation of palliative care policies, including funding
arrangements and structures for service delivery (e.g.
Strengthening palliative care: Policy and Strategic Directions
2011-2015, Victorian Department of Health, 2011).
CABRINI HEALTH APPROACH
Website
Brochure
New Patient Information
Media
Building the
Narrative
Mentorship of
Professional
Bodies
7
Ensuring support
from
communities
1
Informing and
involving clients and
carers
Proposal for funds to
support increased
care packages for
carers
2
Caring for carers
NSAP
Education
Research
Quality
Press Ganey
6
Providing quality
care supported by
evidence
Client and
carers
5
Coordinating care
across settings
Integrated Model
- Consult
- Case Management
3
Working together to
ensure people die in
their place of choice
4
Providing specialist
care when and
where it is needed
Advance Care
Planning
Green Sleeve
Protocol
Boosting Community
Services
Cabrini Hiealth
Integrated Services Model
INTEGRATED PALLIATIVE CARE
CABRINI HEALTH MODEL
C
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n
s
u
l
t
A
d
m
i
s
s
i
o
n
Prahran
Inpatient Consultancy Home
Care
Brighton
Malvern
Ashwood
Elsternwick/Hopetoun
Rehab
Clinical Outcomes
CLINICAL OUTCOMES
Building Rigour in Palliative Care
The Australian Government has, as part of its palliative care
strategy, a goal to build clinical evidence, quality and
measurement in the sector. To this end, it has funded the
Palliative Care Outcomes Collaboration (PCOC), Care Search
and the National Standards Assessment Program.
Why are Health Funds concerned about
Palliative Care?
Senate Enquiry into Palliative Care, October 2012 Committee
commented as follows:
“The committee acknowledges that in the future, demand for palliative
care services will increase as the population ages. As more Australians
invest in private health insurance, the committee calls on the private health
sector to contemplate the role they might play in helping meet the growing
demand for comprehensive palliative care.
The committee considers that further research into the potential role of the
private health sector, including private health insurers, in providing
palliative care services is required and suggests that the federal
government initiate such a review.”
PCOC
A 15% improvement in clinical outcomes has
been demonstrated nationally since 2009 with all but 5 specialist units in Australia
participating in this robust program.
PCOC
By standardising palliative care assessments, PCOC
has:
• Led to the development of a common language in
palliative care
• Allowed for clinical outcomes to be measured and
compared
• Facilitated the development of benchmarking in
the palliative care sector.
PALLIATIVE CARE EXTENDS LIFE
Mean Survival for Lung
Cancer Patients
Mean Survival for Pancreatic
Cancer Patients
Days
p=0.0102
n=493 n=386
Days
p=0.0001
n=700. n=586
279
Average hospice
length of stay was 38
days
189
240
Usual Patients
210
Average hospice
length of stay was 47
days
Hospice Patients
Study in Brief: Comparing Hospice and Non-hospice Patient Survival
•
Retrospective review of 4,493 patients using Medicare claims data
•
Included patients with six terminal diagnoses: congestive heart failure, breast cancer, colon
cancer, lung cancer, pancreatic cancer, prostate cancer.
•
Patients were assigned to hospice group if they had at least one hospice claim within three years
of their diagnosis
•
Average hospice length of stay was 43 days
•
Survival difference was not statistically significant for breast and prostate cancer patients
FACT-L1 Symptom
Management Scores
p=0.03
n=74. n=77
98
LCS2 Symptom
Management Scores
TOI3 Symptom
Management Scores
p=0.009
n=74. n=77
p=0.04
n=74. n=77
Higher scores
indicate fewer
symptoms,
better quality
of life
92
59
53
21
19
Usual
Care
Palliative
Care
Usual
Care
Palliative
Care
Usual
Care
Palliative
Care
VALUE OF PALLIATIVE CARE
A service complementing curative therapies
Curative Treatment
Palliative Care
Palliative Care Services
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Symptom and pain management
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Emotional and spiritual support
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Family conferences
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Conversations about goals of care
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End of life planning
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Care coordination

Educating and supporting clinicians in other care settings
Spec PC
Bereavement
Economic Benefits
Private Health Insurance and Palliative Care
In 2008/2009:
- 77% of palliative care was provided for public patients
- 16% of this cohort were funded by private health funds, and
- 7% by the Department of Veterans Affairs
(AIHW, 2011)
Why are Health Funds concerned about
Palliative Care?
• Palliative care is seen as a “bottomless pit” and not a
“prudent investment”, by some health insurers.
• Concern that there is no legislative barrier to funds placing
palliative care in their schedules.
Private Health Insurance and Palliative Care
Home based palliative care services are premised on the fact the needs of
most palliative care patients can be met through the primary health care
system including the GP.
Benefits are generally structured based around an initial visit, usually by a
nurse and paid on a daily basis, irrespective of the number of visits per
day.
Allied Health is not funded in the payment, nor is medical support,
personal care or equipment and medical supplies.
Bereavement services are provided in most cases.
Private Health Insurance and Palliative Care
Potential benefits of health insurance funds covering out of hospital
home based palliative care services include:
• Decreased re-admission rates.
• Increased savings from lower readmission rates to hospital and shorter
duration of hospital stay.
• Decreased waiting periods for accessing publicly funded home based
palliative care services (which can result in adverse patient episodes
and prolonged hospital admission).
• Immediate access to these services in the home upon discharge significantly improving outcomes.
Future Trends
Influences?
• Equity of Access – from Rolls Royce for some to
Mercedes Benz for all
• Role of the Private sector
• Population aging
• National Standards
• Euthanasia debate
• Person centred care movement
• Education/Research
In the future:
• Have built capacity and capability across the health system to
manage terminal illness and death
• The quality of the way we die won’t be determined by lottery
• Will be patient and family choice
• Will be quality community services
• %futile treatment would have decreased
• Symptom burden at end of life decreased
• Bereavement programs in place
• More even service distribution in 3rd world
• More people comfortable to discuss death and dying in the
community
Health Promotion
• http://www.compassionatecommunities.ie/about#bi
lls-story-video
HALLMARKS OF SUCCESS
Palliative Care Models
Hallmarks of an Integrated Program
1 Embedded Specialist RN
1 Clinicians trust the palliative care
team
2 Palliative care team scrupulous
about care coordination
3 Advance care planning routine for
all patients at end of life
4 Palliative care team highly visible
5 Clinicians share responsibility for
initiating palliative care
6 Clinicians trained to provide
palliative care
2 Inpatient Consult Service
3 Dedicated Inpatient Unit
4 Outpatient Clinic
5 Home Based Care
6 Community Comfort