Patients are frequently discharged from hospital to residential aged care facilities without an advance care plan (ACP) in place, and when one is in place it is not uncommon that it has not been recently reviewed. Hospital teams usually complete a Goals of Patient Care form during admission, but such documents are normally only valid for the duration of the hospital admission. Valuable discussions regarding values and future wishes are often lost on discharge into residential aged care. 

 

In 2021, Bethesda Community Palliative Care (MPaCCS) secured additional funding through the National Project Agreement for Palliative Care in Aged Care (NPA) to create a new role within the service which aims to smooth the transition of patients moving between hospitals and residential aged care. 

 

The MPaCCS Liaison nurse works within four metropolitan hospitals in Perth and speaks to teams regarding goals of care discussions as well as having access to inpatient notes to review information captured about these discussions, during admission. This allows the Liaison Nurse to hand over to appropriate members of the MPaCCS team who follow-up the patient on discharge to residential aged care. MPaCCS can then support the residential aged care staff with completing advance care plans with residents/families which are consistent with these valuable in-hospital goals of care discussions. 

 

The success of the project has been reflected by the uptake of the service in hospitals where the service is available (over 600 admissions in the first 18 months) and also in the increase in updated or completed advance care plans once the patient/resident is back in residential aged care. The role also supports education and awareness within hospitals regarding the limitations that may be present in some residential aged care services, this facilitates smoother discharge and engagement of appropriate services on discharge.

Background: The Nightingale Program is an innovative nurse-led palliative model of care.  Working in partnership with stakeholders the program successfully provides person-centered care for people living with advanced dementia through to end of life. Many people do not view dementia as life limiting and people living with dementia are underserved in accessing palliative care services. Traditionally, there is a lack of skilled professionals with expertise relating to both fields of care. For families there can be high levels of stress facing challenging ethical decisions in relation to end of life care whilst symptoms of dementia can be protracted and complex and need specialist assessment and advice.

Goal of work: Majority of people wish to die at home, which we saw increase again in the pandemic, but a recent AIHW report has shown that only 2.5% of people living with dementia achieve this. Between June 2019 and December 2022, 22% of clients who died in the program died at home. This highlights the need for and value in dementia specific services which can work with traditional palliative care services.

Presentation focus: This presentation will outline our model of care and highlight how to support people living with dementia to understand the trajectory and symptoms and to support choices for future directions through the narrative of consumer case studies. These outcomes will emphasize the value of providing strategies that enable people in the community and residential care to die according to their wishes. By demystifying the signs that indicate a person living with dementia is entering the end of life stage we hope to provide tools for any practitioner to provide supportive dementia palliative care with dignity and choice at the end of life. 

Social Media Summary: Majority of people wish to die at home, but a recent AIHW report has shown that only 2.5% of people living with dementia achieve this. South Australia’s Nightingale Program is a nurse-led palliative model of care.  Working in partnership with stakeholders the program successfully provides person-centered care for people living with advanced dementia through to end of life in South Australia and has seen 22% of clients die at home. This highlights the need for and value of dementia specific services which can work with traditional palliative care services.

Background: 

The Royal Commission into Aged Care Quality and Safety Final Report (2021) highlighted the urgent need for improved access to palliative care and to build workforce capacity within Residential aged care facilities (RACF). There are varied levels of palliative care approaches in residential aged care facilities (RACF). But how do you identify where to start? What facilities need the most support? 

An “Older Persons” team was established as part of the palliative care consult approach to work with the palliative care team and RACFs teams across the District.

AIM: 

To design and implement a model to focus our limited resources and form partnerships with facilities’ to improve palliative and end of life care within the facility.

Method: 

A survey was developed as a self-assessment RACF capability tool for residential aged care facility staff to complete. This tool draws from ACI, ELDAC, CIPIAC and PCOC resources as well as clinical expertise from our specialist palliative care team. The tool was sent to 44 facilities in the Illawarra and Shoalhaven local health district, with completion rate of 54%. The tool was then scored providing an overall score for the facilities on key areas including clinical skills, education, leadership and governance. This data was then used in conjunction with Illawarra Shoalhaven data such as ED admissions for people from RACFs, referral numbers, and occasions of service. 

Outcome: 

Review and integration of all of the data collected and stratify to identify six key facilities within our district. From this process we were able to clearly define how best to focus our limited resources and form partnership with each of the focus facilities, develop action plans and education/mentoring programs.

The Royal Commission into Aged Care recognised that palliative and end-of-life care should be considered core business for aged care providers. Palliative care is a holistic and multidisciplinary approach to care that prioritises the four domains of physical, social, psychological and spiritual wellbeing. Social workers provide holistic and preventative support that can contribute to the quality of life of people in aged care, yet Australian aged care providers do not commonly employ them.

 

To highlight the lived experiences of aged care residents.

 

This presentation is based on a phenomenological approach to exploring the lived experiences of older adults living in residential aged care. The study method involved conducting in-depth interviews, leading to observations and reflections that allowed residents to feel seen, heard and understood. A social worker was employed across several aged care facilities in Melbourne over two years to support residents and family members from admission to the facility, sometimes until the resident’s death.

 

Several overarching themes emerged:

1.  The need to feel heard and understood.
2.  Loss of identity and purpose.
3.  The importance of connection.

 

Exploring an in-depth understanding of an older adult’s lived experience relating to their last stage of life can lead to improvements in palliative care provision.  

 

These findings highlight the need for generalist palliative care providers to focus on the importance of authenticity when supporting older adults living in residential aged care. Whilst frameworks, guidelines, standards and skills training are essential to improve the quality of palliative care provision, we cannot underestimate the significance of compassionate human interactions. Furthermore, the loss, grief and struggle for meaning and purpose experienced by older adults living in aged care, highlights the need for an experienced and skilled multidisciplinary team approach to supporting this population group.

Background: Our home care workforce currently provides care to over 275,000 Australians living, aging, and dying at home. With wide-ranging levels of digital competencies, palliative care knowledge, socio-cultural backgrounds and experience, Home Careworkers (HCW) involvement in co-designing and evaluating the ELDAC Home Care App (the App) was crucial in tailoring the user experience for an underserved workforce. 

Aim: As download numbers are an inadequate proxy measure to assess levels of meaningful digital interaction; the research explores the application of user-driven data capture to understand HCW patterns of engagement with digital palliative care information to support their care provision.

Method: Data capture points were coded within the App's back end during development. Accumulating anonymous user activity data seeks to describe i) patterns of user behaviour, ii) passive or active interactions, and iii) HCW intention and motivation to engage specifically with the App's palliative care information and interactive activities as indicators of digital engagement.
 

Results: With over 1000 downloads and a retention rate of 95.1%, point-in-time analysis suggests HCWs are proactively engaging widely with in-app palliative care information and activities. HCWs are motivated, curating personalised learning plans filling knowledge or practice gaps, creating bespoke self-care activity schedules, and accessing resources facilitating difficult conversations with clients around death and dying. Accumulated data patterns highlight HCW’s palliative care information needs whilst establishing extent of the App’s adoption by the home care workforce.

Conclusion: ELDAC Home Care App offers HCWs a practical guide to caring for their client's palliative care needs. Incorporating data capture as a design requirement provides valuable insights into the digital interaction behaviours of HCWs. Further, patterns of use and depth of engagement could help to identify areas where further investments by the aged care sector are needed to increase HCWs' confidence when providing palliative care to older people dying at home. 

Background
Older patients near the end of life in an acute hospital setting are at risk of experiencing non-beneficial treatments. The Intervention for Appropriate Care and Treatment (InterACT) trial involved three large tertiary hospitals in Queensland and used two screening tools to establish a risk profile for older patients nearing the end of life. 

 

Aim
The aim was to trial a prospective feedback loop to increase clinician awareness of their patient’s risk profile and to measure the impact this had on care review activity timing and occurrence. 

Methods
All patients 75 years and older admitted under fourteen enrolled clinical teams in three hospitals were screened twice weekly. Over 7,000 patients were screened, with 60% identified as ‘at-risk’ of receiving non-beneficial treatment. During the intervention phase, clinical teams were notified of any patients ‘at-risk. Medical notes of each ‘at-risk’ patient were reviewed for evidence of three care review outcomes: clinician-led care review discussion; palliative care referrals; and review of care directive measures in both the usual care and intervention periods. 

 

Results
There were no observed improvements in the three care review outcomes. In two hospitals the probability of reviews of care directive measures reduced by 0.08 and 0.14. In one hospital the number of clinician-led care review discussions reduced by 0.20. Minimal change was seen in the number of palliative care referrals between the usual care and intervention periods (probability changes under 0.05). 

Conclusion
While it was hypothesised that increased awareness of a patient’s risk profile would increase clinician led care review activities, this did not occur. Health system challenges (e.g. COVID-19) and variability in implementation processes between the study sites may have contributed to the failure of the nudge intervention to improve care of hospitalised older people in a complex clinical environment. 

Results published at https://doi.org/10.1186/s12877-022-03554-x