timely specialist palliative care service input (referral)

Timely Specialist Palliative Care Service Input (Referral)

Learning Package

LEARNING OUTCOMES

At the conclusion of this package, participants will be able to: 1. understand the issues and symptoms that may benefit from SPCS

input2. identify when it is appropriate to consider referral to a SPCS3. refer to the local SPCS including all relevant information4. Have a working knowledge of the “Timely Specialist Palliative Care

Input” guideline document5. Feel confident to use the “LM Quick Reference Guide” for referrals

Timely SPCS Input: Learning Package

1. Information you have as a Primary Care Service

• Personal details– What will you have on file?

• Current and previous medical condition/s– Information from GP, Medical

specialist ?

• Current and previous social situation– Initial assessment, carer,

Social Worker ?

• Current functional status– Mobility, ADLs ?

Consider one of the points opposite, then click on the question mark beside that point to see some of the things that will be beneficial.

When you have completed all of the points, click the “Next” button below.


Personal details - What will you have on file?

• Name & address – needed to determine if the person lives in the catchment area of the SPCS

• Phone number – important for the SPCS to make contact to arrange an appointment

• Alternative contact – someone else to call if the SPCS can’t make contact with the person (not home, readmitted prior to appointment etc)

• Does the person have a carer? Include their contact details, and identify if they don’t live with them

Click here to return to previous slide


Current and previous medical condition/s - Information from GP, Medical specialist ?

• Why your service has been seeing this person

• What has changed recently for this person’s medical condition

• What treatments has the person undertaken during this episode of care

• What treatments has the person undertaken prior to this episode of care

• What medications is this person currently taking

• What medications have been tried previously



Current and previous social situation – Initial assessment, carer, Social Worker ?

• Does this person live alone

• Is the person socially isolated (distance, not able to travel etc)

• What community support services are used by this person

• Are there additional community supports that may benefit this person?



Current functional status - Mobility, ADLs ?

• Does this person use any mobility aids – wheelchair outside the house; walking frame at all times etc

• Is there any additional equipment required to assist with personal ADLs – over toilet aid; shower stool; electric bed or recliner chair; lifting device etc

• Does this person need assistance with personal ADLs –who is able to assist with this

• Does this person need assistance with household ADLs – who is able to assist with this?



2. What makes you consider referral to the Specialist Palliative Care Service?

• The person has a terminal illness– Is this known by the person

and their carer

• Symptoms are not adequately controlled– Pain, nausea, dyspnoea,

anxiety etc

• Social or emotional issues not adequately addressed– No carer, Psychological

distress

• Carer is having difficulty managing– Carer strain, carer unwell too




The person has a terminal illness – is this known by the person and their carer

• Brief description of their understanding of diagnosis and prognosis – for both the person and their carer

• Spiritual issues – what does the diagnosis mean for this person, has there been input by Pastoral care, Social work, Minister / Pastor (include their details to maintain continuity)



Symptoms are not adequately controlled - Pain, nausea, dyspnoea, anxiety etc

• Describe all uncontrolled symptoms, their current severity, and treatments previously tried – mainstream and complementary treatments

• Probable cause of the symptom – may not be known, but most likely reason/s

• Possible contributing factors for these symptoms – often one symptom can exacerbate another



Social or emotional issues not adequately addressed - No carer, Psychological distress

• There may be limited, or no family supports located close geographically

• Family conflict or desire to re-establish previously broken relationships

• Spiritual issues – may be cultural, religious, personal beliefs, conflict, unfinished ‘business’



Carer is having difficulty managing - Carer strain, carer unwell too

• Carer may be unsure how they will manage in certain situations

• Role of caring has been extended in time and carer is becoming ‘tired’

• Care needs are increasing, and the carer is unable to express their needs to the person they are caring for

• The carer is also experiencing health and wellbeing issues that reduce their ability to provide the care they have promised



3. How to determine if referral will be appropriate

• LM Quick Reference Guide and Access to Services document

• Local service guidelines / criteria– Have you got your Local

service information?

• Needs Assessment (tools available)– What do you use now?




LM Quick Reference Guide

• Why use the guide? Indicates things to consider if relevant or beneficial to refer to the SPCS

• Will I need to refer to the guide for every person? NO, only those who have a terminal illness you think need help

• Where can I find the guide? Available from the Loddon Mallee Regional Palliative Care Consortium

See the “LM Quick Reference Guide” and the full “Timely Specialist Palliative Care Input” guideline documents on the

LMRPCC Health Workers Page (need internet access)



http://www.lmrpcc.org.au/health-care-workers/referrals/

Local service guidelines / criteria - Have you got your Local service information?

• Local service criteria for admission

• Service Brochure

• Contact details for the local service

• General information about Palliative Care

• If not sure about eligibility, talk with your local Palliative Care staff

(See what specialist services are available across Loddon Mallee region)(need internet access)



http://www.lmrpcc.org.au/patients-carers/services/

Needs Assessment (tools available) - What do you use now?

• What different screening tools do you use – and for what needs? (falls risk, pressure care, depression etc)

• How do you assess the ‘needs’ of a person? - Gap between current condition and desired condition

• Discussion with the person and their carer – not ‘done’ in isolation

• What will be beneficial for the person to improve their quality of life?

• Needs Assessment Tool: Progressive Disease (NAT:PD) includes link to “Can Meet Needs” learning resource (need internet access)



http://www.newcastle.edu.au/research-centre/cherp/can-meet-needs-resource/

http://www.newcastle.edu.au/research-centre/cherp/professional-resources/

4. How to make a referral

• Service Coordination Tool Templates (SCTT)– What are they?

• Information that you have to include on the referral– What is absolutely necessary?

• Specific assessments already completed– Can we use assessments

done by other workers?

• Avoiding duplication– How can we include more

info with the referral?




Service Coordination Tool Templates (SCTT) - What are they?

• Statewide recommend method of information sharing

• Focuses on the client to make sure they have access to the services they need

• Core Templates – consumer information, summary & referral, consent, cover sheet

• Supplementary Templates – Palliative Care, Functional Assessment

• Optional Profiles – if information not included already

Link to download SCTT (need internet access)



http://www.health.vic.gov.au/pcps/coordination/sctt2009.htm

Information that you have to include on the referral - What is absolutely necessary?

• There is a section on the Quick Reference guide to indicate what needs to be included with the referral

• “Phase of Care” definitions are on p2 of the Quick Reference guide. This gives the SPCS an idea of how urgent the need is

• Remember to include a contact person and the phone no of your service / agency / department



Specific assessments already completed - Can we use assessments done by other workers?

• Yes – include copy of relevant assessments with the referral. Make reference to the assessment in the “Description of Issues” box on Summary and Referral p1

• If sending electronically, indicate if other attachments following by fax or mail

• Try to think about what information you have will be useful to the service you are referring to



Avoiding duplication - How can we include more info on the referral?

• Read through what you have first to see where each bit will fit on the referral

• Read through the referral form to see what information is being requested

• Use the Palliative Care Supplement – may be beneficial to complete this first, then add other bits on Summary and Referral, or refer to the supplement instead of re-writing info.

• Be specific when identifying issues and needs



Congratulations! You have now completed the “Timely SPCS Input (Referral)” training package.

You should now be better equipped to: 1. understand the issues and symptoms that may benefit from SPCS input2. identify when it is appropriate to consider referral to a SPCS3. refer to the local SPCS including all relevant information

For more information, contact your local Specialist Palliative Care Service, or the Loddon Mallee Regional Palliative Care Consortium.

Remember to add this to your Continuing Professional Development record.Recommended time is 1 hour of learning.

timely specialist palliative care service input (referral)

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