Improving Discharge planning of palliative care patients from hospital to home.

Transcription

1 Improving Discharge planning of palliative care patients from hospital to home. Geoffrey Mitchell 1 Carol Douglas 2 Anne Bucetti 1 Kerry Clifford 1 Lorna O Doherty 3 Patsy Yates 4 1. University of Queensland 2. Royal Brisbane and Women s Hospital 3. University of Melbourne 4. Queensland University of Technology

2 The problem Discharge of palliative patients from hospital to home can have communication difficulties between patients, care-givers, community based health professionals, and hospitals. What are the needs? How can they be met?

3 Intervention design 1. Assessing the current facilitators and barriers to effective discharge from hospital Focus groups of health professional from hospitals and community Interviews with patients and family 2. Develop resources Patient Held record The Palliative Care Discharge sheet Case Conferences between GPs, community nursing and specialist palliative care staff 3. Evaluate new system Patient impact was assessed by a before- and after-implementation cohort design - Patient and carer quality of life, Patient Enablement

4 Barriers to effective discharge Rushed discharge procedures, Overload of information for the patient and primary caregiver, Failure of essential information to reach the general practitioner (GP) and community services at the time of discharge.

5 What a hand held record should achieve Mechanism for communication between health professionals Giving patients independence Support for carers

6 The Patient-Held Record How can the PHR assist health professionals? Access to contact details of relevant hospital staff A means of communicating with other health professionals Access to discharge documents Palliative Care Plan documents patient EOL wishes The Discipline of

7 Outcomes

8 Patient-Held Record

9 Use of the Hand held record Varied different people used different parts of it Medication list universally used. Carers often used it more that patients: Name changed to reflect this.

10 Patient-Held Record Patients and carers told us: PHR Colourful, cheerful (P) Small place to keep everything together (P) is helping my (elderly) mother be independent and take responsibility. (C) Communication I tidy it the night before and give it to them at the desk [DTU] (P) When I was admitted at [another hospital] I showed the doctor (P) The Discipline of

11 Patient-Held Record Patients and carers told us: Contact Details Useful as I can t remember things well now (C) Feel I have support know who to contact (C) Now my husband will know who to contact to take the equipment back (P) Computerised medication list Very useful. Instructions very clear. Should be given to all patients, especially elderly (P) The Discipline of

12 Patient-Held Record HPs told us: It would make it a bit easier on admission. You know which community service they already have. We don t need to know so much, their GP. (Ward CN) [useful information on readmission] Their functional status..sub-cut drivers and IDCs. They have got their elms..for checking the sheets are written up correctly The Discipline of

13 Patient-Held Record HPs told us: Communication log I wrote in PHR of client s admission to our service, filled in details for other local services and Allied Health (CTN) GP writes notes for hospital specialist such as.how about increasing meds? How about some radiotherapy to right leg? Clinic staff put reply notes in book. The Discipline of

14 The Palliative Care discharge Summary Supplements information in the normal medical discharge summary Based on Gold Standards Framework PEPSI COLA pnemonic

15 Hospital discharge summary Family Doctor named Diagnosis Presentation Treatment in hospital Follow-up and medications on discharge

16 Palliative care plan Treatment advice Emotional Social Personal issues

17 Not for Resuscitation decision Emergency plan Personal wishes Prompt for GP action Follow up plan from PC service

18 HPs told us: Palliative Care Plan Fairly comprehensive. Absolutely great (GP) Definitively very useful. Very useful for us to know if, for example a patient wishes to go to a hospice for EOL care (CTN) The one thing that we love is this part [PCP].. Please, more (CTN). It has given us some structure to work with.is a good clinical tool (PCSN) The Discipline of

19 Results The estimated sample size was not achieved and Type 2 errors are possible. Cohort two was more ill than cohort one.

20 Patient characteristics

21 Cohort 2 interventions PHR only 25 CC only 2 PHR + CC 4

22 Patient Enablement Index As a result of the discharge process from RBWH, are you able to: P able to understand your illness? better able to cope with your illness? able to keep yourself as well as possible? Total Patient Enablement Index 0.066

23 AQEL (Quality of life at the end of life) Patients no change Carers no change

24 Community nurse observations at Day 7 post discharge (Palliative Performance Scale) (10 items) Had sufficient information to plan their care P = Patient more involved in treatment decisions P= 0.074

25 Hospital nurse observations at discharge

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27 PHR has made a difference? (Hospital nurses)

28 Case conferences Case conferences and PCP were highly valued by community professionals. Case conferences changed management plans for some patients. Several systemic difficulties in the discharge process were identified, and processes put in place to overcome these, particularly in embedding the intervention in routine practice.

29 Conclusions Good discharge planning makes a difference to: Patient enablement In particular it improves the patient s ability to understand, and cope with, their illness. Improves Patient outcomes: involvement in care, improve ability to share with the patient s family and loved ones, and reduce wasted time at health services. Influences final management plans.