Background

The Northern Beaches Community Palliative Care Service (NBCPCS) provides a multidisciplinary consultative community palliative care service to a population of over 266,000 people on the Northern Beaches of Sydney. This occurs through clinics and home visits, including to RACF.

Aim

Our challenge has been in managing large patient numbers (approximately 350), whilst aiming to improve patient and family outcomes. The team strongly felt that more proactive strategies were required to recognise deterioration and intervene earlier. Further aims were to improve symptom management, and timeliness of goals of care discussions and planning.

Strategy

A three-pronged approach to redesigning patient management was developed. 
1. A  clinic model for mobile patients was established to facilitate efficient input from multiple members of the MDT in a single visit.
2. A  robust, proactive caseload management strategy was developed using a nurse-led model, with clear expectations for patient monitoring and follow-up. 
3. In order to improve our service’s responsiveness and to recognise deterioration earlier, the Palliative Care Outcomes Collaboration (PCOC) was embedded as a central part of handovers and multidisciplinary team (MDT) meetings. The aim was to more proactively track patients in the unstable, deteriorating and terminal phases.

Outcomes

The three-pronged strategy has now been established and is collecting data. By improving responsiveness and delivering proactive care, we aim to show a reduction in out of hours phone calls and acute hospital admissions, and an improvement in PCOC benchmark reports. An initial reduction in after hours calls has already been observed, and interdisciplinary and cross-team collaboration has improved. Staff will complete a survey to ensure feedback from the MDT is captured.

Conclusion

The NBCPCS has developed proactive strategies to improve patient and family outcomes, as well as collaborative care within our team. We believe that our strategies can be replicated in other community palliative care services to improve patient care.