Wodonga Palliative Care Service

Jenny Sutter, Stacey Heer, Leanne Hills

First, Some Background

• Increasing demand on palliative care service

• Increasing demand for coordinated care

• Increasing need for patients to manage

own health care

Our Service

• Health information not being exchanged

• Patients struggling to maintain autonomy

• Patient satisfaction surveys – carers want

more support

Project Aims…….

Improve Coordination of Care and Communication

Improve Patient Control in Own Care and Decision Making

Methodology

• Communication Tool – patient diary

• Adaption versus development

• Mid North Palliative Care Referral and

Planning Project – patient diary

• Challenge – adapt to suit our community

based service

Trial Distribution Criteria

• Capacity • Ongoing palliative care• Not in a residential facility• Not terminal or rapidly

deteriorating

The Modern Health Care System

• Care occurs increasingly in home

• Treatments more complex

• Numerous health care providers

• Increased need for patients to self care

Provide Accurate Medical History

and Medication History

Modern Health Care requires patients to . . . . .

Communication Barriers For Patients

•Poor Health Literacy•Language Barriers•Cognitive and Thinking issues •Affects of disease and treatment

Communication Effects: Patients

•Don’t understand or follow treatment•Miss appointments•Take medications incorrectly•Low continuity of care: low patient satisfaction•More complaints

Communication Effects: Health Care Worker

•Unnecessary tests•Unaware of all health care providers•Double up on referrals•Low continuity of care •Medical errors

Better Continuity of Care

Fewer hospitalisations

Fewer emergency department presentations

Lower repetition demands on patient

Patient Held Records……Better Communication

Patient needs more likely to be metHigher patient autonomyLess burden on health care workersEnd of life choices met better

and financial

Diary includes

• Enduring power of attorney

(medical / financial)

• End of Life Directive Contact

• End of Life Wishes

This is special place where you can think about and perhaps write some notes on what is important to you, regarding your care at the end of life.

For example:

 

“It is important to me to stay at home for as long as possible”

Changes from review:

Pain chart

Extra plastic sleeve for reports

Extra test results pages

Removable calendar at back

Name change to Care Diary

FeedbackMost helpful sections: medication, appointments, glossary

Everything in one place & easy to use

Few took diary to specialists

Approximately half took to hospital

Carer Feedback

• Improved communication between health professionals and family

•Felt more in control of care

•Comments by professionals were positive

Ongoing Issues for the Care Diary

$ Cost $

No communication tool is perfect…..

Keeping the diary up to date Future reviews

applicable for all….

The care diary is not

Acceptance by

Health Care Providers

Thank you, questions, questions…….