Nurse Practitioner - Palliative Care

Karen GlaetzerNurse Practitioner – Palliative CareSouthern Adelaide Palliative ServicesLecturer (B) – Flinders University

Southern Adelaide Palliative Services

> Regional Service – Population 330,000> Interdisciplinary team> Clinical services, education and research> 1200 referrals each year> 380 current clients> Seamless care model

Gaps identified in Service Provision

> 30-40 families each year identified by SAPS whose needs were not adequately addressed

> 82 referrals in 2002 under the age of 50> Resource intensive> Utilised Multiple Service Providers> Complex psychosocial/psychological issues> Primary service providers with limited specialist

palliative care skills> Limited availability of institution based

resources

Triage Criteria> Chronic complex mental health history Long term mental health history whorequire ongoing assessment and treatment.

> Multiple service providers More than 3 community service providers (GP,RDNS, Dom Care etc).

> Complex symptom issues Patients who have significant, complex symptoms (physical or psychological), that require advanced skills to assess andmanage.

> Family dysfunction Families who have demonstrated difficulty coming to terms with the diagnosis/prognosis and where there is significant ongoing conflict

> Complex individual caregiver issues Carers who have significant ongoing personal (physical or psychological)and who demonstrate difficulties adapting to the role of carer.

NP referrals meet 2 of these criteria

Nurse Practitioner - Palliative Care

> Direct clinical service provision to palliative clients with overwhelmingly complex needs

> Coordination of case management, clinical problem solving, clinical decision making and advance care planning

> New patient OPD Clinics> MND Clinic

Nurse Practitioner - Palliative Care

> Provision of education to patients, families and professional care providers

> Initiate and participate in research/projects

> Rural Mentor role> Contributes to State and National Policy

(State Plan)

M T W Th F

Admin OPD

NHS

Teaching Research Research Meeting

Project Work

Team Meeting

Education

Service Development

Home

Visits

(far south)

Home Visits

4pm Nurses Meeting

OPD

(alt MND, new patients)

Admin

OPD Clinics

> Hospital Funded OPD – not medicarised> 3 patients – 1 hour appointments> Palliative Medicine Consultant holds

concurrent review clinics> 15 - 20 minute overlap to assist in co-

signing investigations or to provide scripts> Next appointment booked with Palliative

Medicine Consultant

NP Role Evaluation

Journal

> Maintained professional journal over the first 6 months of role> Recorded

• Referral numbers from SAPS and reason for referral• Referral numbers from other health services and reason for referral• Planned and unplanned contacts• Input into care planning• Main activity – referral to others, consultation, prescription and ordering

rates• Non-clinical activities

Research/projects Education Networking and higher level activities

Results – Snapshot data

> Pre• Diary

Mean contacts per day = 3.14 Number of NP criteria met = 2.25 Mean satisfaction scores = 8.56/10

> Post• Diary

Mean contacts per day = 1.92 Number of NP criteria met = 2.6 Mean satisfaction scores = 9.16/10

Results – Staff questionnaire

> Community team n=8/11• Identifying impacts of NP

Possible reduced need for medical input Streamline reviews and assessment Reduce stress by reducing complexity of caseloads

• Responsibilities Varied opinion (lessened for some, others thought no change) Consultant seen as supporting NP

• Support Most – NP as a support and resource, but varied opinion

• Attitude to NP role Can be viewed as privileged, choice of patients, protected time

• Service issues Who decides NP patients, how does triage work How does follow-up get handled

Results – Journal

Number of patients triaged 28%

Education activities 17%

Discussions with external nursing/allied 12%

Discussions with SAPS medical 9%

Referrals to others 8%

Discussions with external medical 6%

Research/project 6%

Discussions with SAPS nursing/allied 5%

Drug/treatment advice 5%

Admissions arranged 2%

Referred to NP intervention 2%

Clinical load, MND clinics NA

Results

> Number referred to NP = 27> Reason for referral

• Complex symptoms = 8• Family dysfunction = 5• Multiple health providers = 4• Complex mental health history = 2• Caregiver issues = 8

Site of death (%)

Mean age

% male

Cancer/non cancer %

Mean LOS (days)

Home Pall care

Hospital Not specified RACF Alive Mean MO contacts

SAPS 71.9 56 82:18 60 9 18 25 9 6 33 1.82

NP 49.2 55 91:9 69 52 33 14 0 0 1 1.72

Conclusions

> Patient profile• By definition, more complex, more severe problems

• Younger

• Die at home

> Difficult to evaluate• Small numbers

• Limited timeframe

• Methodological issues

Conclusions

> Triage detects 1/3 patient numbers, other referrals after clinical assessment and as problems arise

> Journal• Operates at local, regional, state and national level

Education Policy Research/project Support and consultative

• Extended practice reflected (within legislative limitations)• Case load reflects patients identified through triage criteria

Discussion

> Outstanding features of the role• High numbers of rural contacts

Those services where SAPS is already aligned Using the knowledge and skill base of NP

• Maintains statewide MND clinic and support service

• Local, regional, state and national involvement in Education Policy Consultative and support roles

Possible Palliative Care NP Roles

> Nurse led inpatient beds> Aged care/ Palliative care> Chronic disease/Palliative care> Consultative Clinics – hospital,

community, RACF> Community

Contact Details

Karen GlaetzerRN BN NP Cert Onc Cert Bioethics Grad Cert Health(Palliative Care) MNg (Nurse Practitioner) MRCNANurse Practitioner - Palliative CareSouthern Adelaide Pallliative ServicesRepatriation General Hospital700 Goodwood RdDaw Park South Australia 5041ph. 61 8 8275 1732fax. 61 8 8277 4957Email. Karen.glaetzer@health.sa.gov.au