Palliative care and GP teams – defining the optimum
Peter Woolford
Simon Allan
Scallop season opens this weekend!!!
Place of death over 3 hospices
Die at home 36% 56% 52%
Die in hospital
10% 12% 22%
Die in hospice
37% 7% 14%
Die in residential care
17% 25% 12%
GPs are integral to providing best care
GPs are widely regarded, in all developed countries, as being pivotal to successful, high quality cost-effective home based and community care.
GPs are integral to providing best care
They provide contextural knowledge of a patient, family dynamics, history of illness, routine medical surveillance, early intervention to prevent or control symptoms, medical care of carers and bereavement surveillance of carers. Mitchell 2004.
Both Programmes ultimate goals
“To support the terminally ill patients who choose to die at home, and to support the GPs to deliver generalist palliative care who are able to support this option”
Aims
PC1 To fulfil the expressed
wish of patients who have a stated preference to die at home
PC2 To deliver coordinated
primary care to support patients their families/whanau through the end of life experience
Access to hospice beds
PC1 Limited, none in the
immediate vicinity. Available on a limited
basis across town
PC2 Access available locally
and reasonably easily
Number of practices enrolled in the programme
PC1
21 of the 25 eligible practices
84%
PC2
11 of the 19 eligible practices
58%
Number of GPs involved
PC1
36 of an eligible 100 36%
PC2
21 of an eligible 71 30%
Patients enrolled in the study year
PC1
114
PC2
110
Age of patients enrolled
PC1
Range 24 – 94 Mean 61 More cancer
diagnoses – 93%
PC2
Range 45 – 100 Mean 81 Less cancer diagnoses
- 46%
Deaths
PC1 Range of days in
programme 1 – 275 Median 31.5 76 (66%) patients died 55 (72%) died in their
own home/residence 5 died in hospital
PC2 Range of days in
programme 0 -299 Median 30 days 9 (8%) patients died 2 (2%) died in their own
home/residence
Services provided by GPs
PC1 Practice visits – 108 Home visits – 304 Extended HV – 80
Total contacts - 492
PC2 Practice visits – 34 Home visits – 31 Initial visit with ACP –
110 After hours visits – 15
Total contacts - 190
What did the programmes have in common?
Shared ultimate goals Quality GPs committed to providing good palliative
care Strong education package for GPs Access to specialist advice Access to funding for patients. In PC1 this was
primarily for home visits to dying patients, in PC2 there was a strong emphasis on completion of an ACP
How did the programmes differ?
PC1 Used Irene Higginson’s
POS. This was dropped early
on as it became clear it was not transferable
PC2 Used an Advance Care
Plan, which remained a compulsory part of the programme
How did the programmes differ?
PC1 Focused on care in the
home and inevitably therefore the last 3 months of life.
PC2 Focused on the ACP,
and thus more non cancer patients were enrolled
How did the programmes differ?
PC1 Has a GP taking an
active part in the weekly multidisciplinary team meeting
PC2 Has no regular GP
involvement in the hospice
How did the programmes differ?
PC1 Has a back up call
system of 3 GPs, available for the patient’s regular GPs if they are unavailable
PC2 Has a system relying
on regular GPs, hospice nurses and palliative care specialists who do not visit
How did the programmes differ?
PC1
Funding is focused on home visits
PC2
Funding is (accidentally) focused on ACP
80% of patients being supported to die at home
Spinoffs Fulfilling patient wishes Healthier for the patient Healthier for the patients’s family Healthier for communities Decreased acute and inpatient demand on
hospitals
An integrated model of care
GP involvement in hospice – MDT Hospice nurses always using the GP as first
port of call for medical advice Hospice nurses carrying medication and
being able to administer on GP advice PC specialist acting as consultants,
particularly consulting in home with GP
An integrated model of care - 2
All team members being proactive using an anticipatory model of care. Palliative care lends itself to this
Provide ongoing education in a variety of formats
web based/short course/ordinary CME
diploma/masters level (grants by PHO)
An integrated model of care - 3
GP’s being available 24/7– No need for individual GP to be 100% available– Need to be flexible– May only need phone contact– May delegate to partner– Have a back up system of GP cover
An integrated model of care - 4
Pay patient fees for home visits Encourage/pay GPs for ACPs
– Link in with national programme– Not compulsary
Integration across services
Tuia te rangi e tu iho neiTuia te papa e takoto nei.
Join the sky aboveTo the earth belowJust as people join together
As sky joins to earth, so people join together. People depend on one another