Background Specialist palliative care (SPC) is a finite resource that manages community patients, including those in residential aged care facilities (RACF) with complex needs. With referrals increasing, excessive time was spent reviewing stable residents. While these residents still needed a palliative care approach, our case-based model of care was proving unsustainable.

Aim To reduce the number of residents who did not need SPC on the community patient list from 15 to 5 per week by having an active discharge process.

Method As part of a structured Stanford-SPHERE Quality Improvement End of Life Program, our team used an evidence-based A3 problem-solving process with the goal of discharging residents who had been stable for four weeks. 

Analysis A cause and effect diagram highlighted that the service did not have referral and discharge criteria or standardised processes. Key drivers necessary for the goal to be met included having a clear model of care and for RACFs and general practitioners to be confident managing residents with general palliative care needs. 

Interventions Once the resident met the discharge criteria, a comprehensive discharge process, including communications with the resident, family and general practitioners, was implemented to ensure advance care plans and advice for anticipatory end-of-life medications were in place. A run chart tracked the weekly discharges.  When the target was met, the four-week wait to discharge was reviewed, allowing one-off consultations.

Results In 14 weeks, the service discharged 27 residents without any being relinked and reached its target of only having 5 stable residents on the patient list within 5 weeks of the active discharge process.

Conclusion The systematic process of identifying a gap and performing current state analyses to highlight key drivers can result in interventions to efficiently increase the rate of discharges from the community RACF palliative care team.