Introduction:

The Northern Beaches Hospital (NBH) is tertiary hospital with a consultative palliative care service comprising staff specialists and a clinical nurse consultant (in-reach from HammondCare). The Northern Beaches Community Palliative Care Service (HammondCare) is a team providing multidisciplinary care to patients in their homes. Northern Sydney Home Nursing Service (NSHNS – Northern Sydney Local Health District) also provides community nursing care to patients in their homes. 

The problem identified:

As the acute hospital palliative care team is a busy consultative service, referrals to community palliative care delegated to teams on discharge were at times either incomplete or missed, or sent to the incorrect organisation. Given the number of services and organisations involved in the care of palliative care patients, including two different eMR systems, details regarding the ongoing care of patients were at times either absent, or not handed on to the correct service.

The intervention:

Each week a community multidisciplinary team meeting is held, with the key community services involved in care of palliative care patients present – HammondCare and NSHNS. In 2022 the acute hospital palliative care consultative team was invited to virtually attend the community MDT meeting.

Results:

The acute hospital palliative care consultative team (the CNC) has been regularly attending (virtually) a 5-10 minute slot during the weekly community MDT meeting, at which verbal handover can occur to all the relevant services, and referrals of discharged patients checked. The attendance has improved communication between our services, and also follow up of discharged patients.

Conclusion:

Palliative care patients frequently move between settings and have involvement from multiple services. We have found involvement from the acute hospital palliative care team in community MDTs to be a simple, low cost intervention that has contributed to collaboration between services and improved continuity of care for patients.