The SMART CLINIC

Symptom Management Assessment and Referral Team Clinic – a multi focused approach to a palliative care outpatient clinicPresenters:Dr Adrian Dabscheck –Palliative Medicine Consultant, Western HealthMs Fran Gore – Manager, Mercy Palliative Care Services

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Our messages:

-Identify the need – know your community

-Persistence – be clear in what you want

-Patience - lots of it!

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How it all began

Western Health and Mercy Palliative Care share a long standing relationship.

Outreach programme commenced in 2008 resulting in improved patient outcomes.

↑ symptom management

↑ deaths at home

↑ direct admission to inpatient palliative care units

Achieving patient goals of care

Access to hospital pharmacy for non PBS medications

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How it all began – identifying the need

Both Western Health and Mercy Palliative Care had recognised that a group of patients were ‘slipping’ through the gaps.

Oncology patients seen exclusively as outpatients often had symptom issues that could potentially benefit from palliative care input – either consult service or community palliative care.

These patients are often not referred to palliative care until admitted as an inpatient when disease/symptoms become problematic.

Late referral to community palliative care, or not referred at all and family missing out on bereavement support.

Avoidable presentations to ED or multiple hospital admissions.

Often multiple medication issues

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How it all began

There was a perception by Cancer Services at Western Health that many of the Oncology patients would gain from earlier Palliative Care in put.

The success of the Outreach program gave Western Health the confidence to build on that and work further to remove the institutional barriers between Hospital and Community care.

Appointment of full time Palliative Medicine Consultant to WH.

Had experience of working in an outpatient palliative care with pharmacy input.

Inclusion of community palliative care would enhance patient outcomes

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Where to start? – be clear in what you want

Main challenges:

•Funding

•Space

•Bureaucracy

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Funding

Application for grant funding to Western and Central Melbourne Integrated Cancer Service – successful.

Funding for 12 months:

Project Officer

Clerical and nursing support for outpatient clinic

Pharmacy support for clinic

Need to prove need and sustainability for this period

Only for patient with a malignant diagnosis for the period of the project.

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Commencement

Recruitment and appointment of Project Officer Feb 2012 – Feb 2013

Review of clinic space in outpatient department – conversion to MBS clinics – more about that later!

Application to WH Ethics committee for approval as a Quality Assurance programme

Project Committee established comprising key stakeholders – internal and external and a consumer representative

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Background information

Number of unscheduled appointments for palliative care consultants in

Day Oncology – 92 informal palliative medicine consults in 12 month period

Outpatient Department – 74 informal palliative care medicine consults in Gen Oncology in 12 month period

Back ground survey conducted:

What amount of time do medical staff time currently spent on symptom management and end of life issues? – survey of consultants and registrars from all tumour groups.

Could a symptom management clinic with a palliative approach assist with this?

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Background information

83% response rate from 70 medical staff from tumour streams at Western Health

74% of these were consultant medical staff

26% were Registrars

All were potential referers

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Background information

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Results

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Background information

91% stated they would refer to a clinic set up specifically for symptom control issues

Benefits of such a clinic were rated by the respondents in the following order:

1.Improved symptom management

2.Improved pain control

3.Facilitating community palliative care referral

4.Facilitating discussion of end of life issues and patient goals of care

5.Streamlining specialised care from general ( oncology) clinics

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Background information

•Supported anecdotal evidence of need

•Survey served as an awareness raising exercise

•All tumour groups supportive of clinic

“How soon can you start!”

• Divisional Director and Manager supportive

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Commencement

•Project committee and working groups established

• Clinical• Evaluation = sustainability• Pharmacy

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Commencement

•First clinic held May 31st - along side colorectal clinic

•Referrals slow at first

•However, benefits apparent from the onset

• Provision of emergency injectable medications• Linking to community palliative care sooner rather than later

• 24 hour number

• Bereavement support

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Challenges and learnings - patience

•Working within an MBS clinic environment

• Income generation• Medication dispensing

• Clinic space!!!

• Ensuring data collection to prove sustainability

•Data entry – who does

•Software

• Availability of Pharmacy staff – no backfill for leave

• Change of time/day and location of clinic

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Results to date:Consultations 18 new 6 review

Referral source Colorectal Unit - 4 Lung unit - 4 General Oncology - 5 Emergency Day OncologyRenal Unit BreastOnc. Ward - 1 each

Reason for referral 3 Pain Management 8 Combination Pain and Symptoms4 other symptoms

2 link to community palliative care

1. Regular blood transfusions organisation

Pharmacy input 16 Pharmacy Care Plan commenced

5 provided with injectable medications

16 medication education

1 community pharmacy contact

Pain scores reduced 6 out of 8 ↓ pain scores

Not all able to be followed up

Referrals to community palliative care

12

Deaths 1 – at home

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Feedback

Patient survey developed based on the UK Picker Institute examining patient and carer experience around the domains of:

Respect for patient centred values

Coordination and integration of care

Information, communication and education

Physical comfort

Emotional support

Welcoming the involvement of family

Transition and continuity

Access to care

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What do patients say?

•Number of surveys to date: 8

•Themes

• Positive experience of palliative care• Better understanding of medications• Family/carer involvement• Identification of palliative care as part of

treating team

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Challenges to date• Pharmacy issues related to MBS Model.

• Different model than we planned for as it does not run in parallel with Oncology OP, due to lack of physical space.

• The usual teething problems one would anticipate setting up a new clinic in a very busy public hospital, but there has been an amazing amount of good will to assist clinics establishment.

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Progressing the SMART Model

• New Symptom Control Clinic at Sunshine Radiotherapy Centre.

• Palliative Medicine works in parallel with Radiation Oncology.• Successful from an Institutional perspective and from patient

perspective as shown by survey results.• Working towards using SMART Clinic model at Sunshine

Radiotherapy Centre.

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Acknowledgements

•WH Divisional Director – Ms Jenny Walsh

•WH Director of Cancer Services– Prof Michael Green

•WH Cancer Services Manager – Ms Adele Mollo

•WH Director Palliative Care – Dr Maria Coperchini

•Mercy Health

•Project Officer-Kathy Hendry

•WCMICS as project funding body