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PALLIATIVE CAREWhy?
Australian College of NursingVictorian Chapter
7 February 2013
Helen WalkerCabrini Palliative Care
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•Current Scene•Clinical Outcomes•Economic Advantages•Role of Health Funds•Future Trends
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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.
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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
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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)
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PROJECTED DEATHS
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0–45–9
10–1415–1920–2425–2930–3435–3940–4445–4950–5455–5960–6465–6970–7475–7980–8485–8990–94
95+
450,000 300,000 150,000 0 150,000 300,000 450,000
Female Male
Insured Persons ('000)
Age
Cate
gory
Insured persons by age cohort
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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).
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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)
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DEATH TRAJECTORIES
Understanding what happens at end of life, helps us to plan, involve patients and families, support and provide best care.
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Time course to death
Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death
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Time course to death
Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death
Cancer
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Time course to death
Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death
Chronic illness
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Time course to death
Sudden death vs Cancer vs Chronic Illness vs Frail Aged Sudden death
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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)
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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)
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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.
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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
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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)
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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).
Strategic Frameworks
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CABRINI HEALTH APPROACH
Advance Care Planning
Green Sleeve Protocol
Mentorship of Professional
Bodies
NSAP
Education
Research
Quality
Integrated Model- Consult
- Case ManagementCabrini Hiealth
Integrated Services Model
6Providing quality
care supported by evidence
1Informing and
involving clients and carers
2Caring for carers
3Working together to ensure people die in their place of choice
4Providing specialist
care when and where it is needed
5Coordinating care
across settings
7Ensuring support
from communities
Client and carers
Boosting Community Services
Proposal for funds to support increased care packages for
carers
Website
New Patient Information
Brochure
MediaBuilding the
Narrative
Press Ganey
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INTEGRATED PALLIATIVE CARE CABRINI HEALTH MODEL
Providing specialist services to ensure all patients/residents in a Cabrini Health Facility will receive end of life care – the right setting in the right way
Admission
Consult
Inpatient Consultancy Home
Care
Brighton
Prahran
Ashwood
Elsternwick/Hopetoun
Rehab
Malvern
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CLINICAL OUTCOMESClinical Outcomes
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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.
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Why are Health Funds concerned about Palliative Care?Senate Enquiry into Palliative Care, October 2012 Committeecommented 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.”
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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.
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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.
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PALLIATIVE CARE EXTENDS LIFEMean Survival for Lung
Cancer Patients
Usual Patients
Mean Survival for Pancreatic Cancer Patients
Hospice Patients
Daysp=0.0001
n=700. n=586
Daysp=0.0102
n=493 n=386
240
279
189
210
Average hospice length of stay was 38 days
Average hospice length of stay was 47 days
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
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FACT-L1 Symptom Management Scores
Usual Care
p=0.03n=74. n=77
92
98
Higher scores indicate fewer symptoms, better quality of life
Palliative Care
Usual Care
19
21
Palliative Care
Usual Care
53
59
Palliative Care
LCS2 Symptom Management Scores
p=0.04n=74. n=77
TOI3 Symptom Management Scores
p=0.009n=74. n=77
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VALUE OF PALLIATIVE CAREA service complementing curative therapies
Palliative Care Services
Symptom and pain management
Emotional and spiritual support
Family conferences
Conversations about goals of care
End of life planning
Care coordination
Educating and supporting clinicians in other care settings
Curative Treatment
Palliative Care Spec PC Bereavement
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Economic Benefits
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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)
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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.
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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.
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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.
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Future Trends
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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
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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
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Health Promotion
• http://www.compassionatecommunities.ie/about#bills-story-video
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HALLMARKS OF SUCCESSPalliative Care Models
1 Embedded Specialist RN2 Inpatient Consult Service3 Dedicated Inpatient Unit4 Outpatient Clinic5 Home Based Care6 Community Comfort
Hallmarks of an Integrated Program
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 care6 Clinicians trained to provide
palliative care
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