Wodonga Palliative Care Service Jenny Sutter, Stacey Heer, Leanne Hills.
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Transcript of Wodonga Palliative Care Service Jenny Sutter, Stacey Heer, Leanne Hills.
Wodonga Palliative Care Service
Jenny Sutter, Stacey Heer, Leanne Hills
First, Some Background
• Increasing demand on palliative care service
• Increasing demand for coordinated care
• Increasing need for patients to manage
own health care
Our Service
• Health information not being exchanged
• Patients struggling to maintain autonomy
• Patient satisfaction surveys – carers want
more support
Project Aims…….
Improve Coordination of Care and Communication
Improve Patient Control in Own Care and Decision Making
Methodology
• Communication Tool – patient diary
• Adaption versus development
• Mid North Palliative Care Referral and
Planning Project – patient diary
• Challenge – adapt to suit our community
based service
Trial Distribution Criteria
• Capacity • Ongoing palliative care• Not in a residential facility• Not terminal or rapidly
deteriorating
The Modern Health Care System
• Care occurs increasingly in home
• Treatments more complex
• Numerous health care providers
• Increased need for patients to self care
Provide Accurate Medical History
and Medication History
Modern Health Care requires patients to . . . . .
Communication Barriers For Patients
•Poor Health Literacy•Language Barriers•Cognitive and Thinking issues •Affects of disease and treatment
Communication Effects: Patients
•Don’t understand or follow treatment•Miss appointments•Take medications incorrectly•Low continuity of care: low patient satisfaction•More complaints
Communication Effects: Health Care Worker
•Unnecessary tests•Unaware of all health care providers•Double up on referrals•Low continuity of care •Medical errors
Better Continuity of Care
Fewer hospitalisations
Fewer emergency department presentations
Lower repetition demands on patient
Patient Held Records……Better Communication
Patient needs more likely to be metHigher patient autonomyLess burden on health care workersEnd of life choices met better
and financial
Diary includes
• Enduring power of attorney
(medical / financial)
• End of Life Directive Contact
• End of Life Wishes
This is special place where you can think about and perhaps write some notes on what is important to you, regarding your care at the end of life.
For example:
“It is important to me to stay at home for as long as possible”
Changes from review:
Pain chart
Extra plastic sleeve for reports
Extra test results pages
Removable calendar at back
Name change to Care Diary
FeedbackMost helpful sections: medication, appointments, glossary
Everything in one place & easy to use
Few took diary to specialists
Approximately half took to hospital
Carer Feedback
• Improved communication between health professionals and family
•Felt more in control of care
•Comments by professionals were positive
Ongoing Issues for the Care Diary
$ Cost $
No communication tool is perfect…..
Keeping the diary up to date Future reviews
applicable for all….
The care diary is not
Acceptance by
Health Care Providers
Thank you, questions, questions…….