Palliative care and GP teams – defining the optimum

Peter Woolford

Simon Allan

Scallop season opens this weekend!!!

Place of death over 3 hospices

Die at home 36% 56% 52%

Die in hospital

10% 12% 22%

Die in hospice

37% 7% 14%

Die in residential care

17% 25% 12%

GPs are integral to providing best care

GPs are widely regarded, in all developed countries, as being pivotal to successful, high quality cost-effective home based and community care.

GPs are integral to providing best care

They provide contextural knowledge of a patient, family dynamics, history of illness, routine medical surveillance, early intervention to prevent or control symptoms, medical care of carers and bereavement surveillance of carers. Mitchell 2004.

Both Programmes ultimate goals

“To support the terminally ill patients who choose to die at home, and to support the GPs to deliver generalist palliative care who are able to support this option”

Aims

PC1 To fulfil the expressed

wish of patients who have a stated preference to die at home

PC2 To deliver coordinated

primary care to support patients their families/whanau through the end of life experience

Access to hospice beds

PC1 Limited, none in the

immediate vicinity. Available on a limited

basis across town

PC2 Access available locally

and reasonably easily

Number of practices enrolled in the programme

PC1

21 of the 25 eligible practices

84%

PC2

11 of the 19 eligible practices

58%

Number of GPs involved

PC1

36 of an eligible 100 36%

PC2

21 of an eligible 71 30%

Patients enrolled in the study year

PC1

114

PC2

110

Age of patients enrolled

PC1

Range 24 – 94 Mean 61 More cancer

diagnoses – 93%

PC2

Range 45 – 100 Mean 81 Less cancer diagnoses

- 46%

Deaths

PC1 Range of days in

programme 1 – 275 Median 31.5 76 (66%) patients died 55 (72%) died in their

own home/residence 5 died in hospital

PC2 Range of days in

programme 0 -299 Median 30 days 9 (8%) patients died 2 (2%) died in their own

home/residence

Services provided by GPs

PC1 Practice visits – 108 Home visits – 304 Extended HV – 80

Total contacts - 492

PC2 Practice visits – 34 Home visits – 31 Initial visit with ACP –

110 After hours visits – 15

Total contacts - 190

What did the programmes have in common?

Shared ultimate goals Quality GPs committed to providing good palliative

care Strong education package for GPs Access to specialist advice Access to funding for patients. In PC1 this was

primarily for home visits to dying patients, in PC2 there was a strong emphasis on completion of an ACP

How did the programmes differ?

PC1 Used Irene Higginson’s

POS. This was dropped early

on as it became clear it was not transferable

PC2 Used an Advance Care

Plan, which remained a compulsory part of the programme

How did the programmes differ?

PC1 Focused on care in the

home and inevitably therefore the last 3 months of life.

PC2 Focused on the ACP,

and thus more non cancer patients were enrolled

How did the programmes differ?

PC1 Has a GP taking an

active part in the weekly multidisciplinary team meeting

PC2 Has no regular GP

involvement in the hospice

How did the programmes differ?

PC1 Has a back up call

system of 3 GPs, available for the patient’s regular GPs if they are unavailable

PC2 Has a system relying

on regular GPs, hospice nurses and palliative care specialists who do not visit

How did the programmes differ?

PC1

Funding is focused on home visits

PC2

Funding is (accidentally) focused on ACP

80% of patients being supported to die at home

Spinoffs Fulfilling patient wishes Healthier for the patient Healthier for the patients’s family Healthier for communities Decreased acute and inpatient demand on

hospitals

An integrated model of care

GP involvement in hospice – MDT Hospice nurses always using the GP as first

port of call for medical advice Hospice nurses carrying medication and

being able to administer on GP advice PC specialist acting as consultants,

particularly consulting in home with GP

An integrated model of care - 2

All team members being proactive using an anticipatory model of care. Palliative care lends itself to this

Provide ongoing education in a variety of formats

web based/short course/ordinary CME

diploma/masters level (grants by PHO)

An integrated model of care - 3

GP’s being available 24/7– No need for individual GP to be 100% available– Need to be flexible– May only need phone contact– May delegate to partner– Have a back up system of GP cover

An integrated model of care - 4

Pay patient fees for home visits Encourage/pay GPs for ACPs

– Link in with national programme– Not compulsary

Integration across services

Tuia te rangi e tu iho neiTuia te papa e takoto nei.

Join the sky aboveTo the earth belowJust as people join together

As sky joins to earth, so people join together. People depend on one another