Reducing Avoidable Admissions in Rural Palliative Care

摘要

Introduction : Nationally, palliative care separations have increased by 51% over a decade, and demand is projected to rise by 4.6% yearly. Community-based palliative care is 50%-300% less expensive than hospital-based care, yet whilst 74% of Australians wish to die at home only 16% actually do. Unplanned admissions occur due to lack of after-hours care, inadequate symptom management and poorly coordinated care and many patients have not made their wishes for care explicit through completion of an Advance Care Directive (ACD). General Practitioners (GPs) should play a central role as community palliative care delivery by GPs reduces hospitalisations and increases home deaths. Barriers to involvement by GPs include unwillingness to provide after-hours care, and lack of knowledge, confidence and experience in palliative medicine. Methods : A quasi-experimental design utilising an intervention and control group based on neighbouring rural Community Nursing Areas (CNA) was used. Participants were referred by general practices and specialists. Change implemented : The project was a collaboration between the state Northern NSW Local Health District , the regional primary care organisation (then known as North Coast NSW Medicare local) and the then Regional GP training organisation. Patients in the interventaion CNA received standard care from community nurses plus the trial General Practice Registrar (GPR) service. The GPR services will be described. Aim and theory of change : The aim was 1)to increase the proportion of patients who died at home (as wished) and proportion with an ACD, and 2) reduce the number of hospital admissions and bed-days per 100 patient-days. We also aimed to develop enduring palliative care skills and experience in the GP workforce. Targeted population and stakeholders Palliative care patients in a rural town and surrounds. 99 intervention and 92 controls. The design, funding and governance was shared across the 3 collaborating organisations. Timeline : The program ran over a two year period from 2013-15 Highlights : Controls were twice as likely to have eight or more bed-days than the intervention group (OR 2.089 (95%CI 1.100 – 3.967); p=0.024) per 100 days. After adjusting for age and residence in an RACF, analysis showed that controls were ~three times more likely to have two or more admissions than the intervention group (OR 3.12 (95%CI 1.72 – 5.92); p 0.001) per 100 days. There was a substantial improvement in ACD completions compared to those in the control area. Sustainability and transferability : The registrar gained supervised experience in palliative care to carry into their GP careers. Subsequent General Practice Registrar positions in palliative care have been developed in this and neighbouring health districts. Conclusions : This pilot provides preliminary evidence that a GPR palliative care facilitator can significantly reduce rural palliative care patients’ hospital admissions and inpatient days. It is a model that can be replicated and sustained. References: 1- T F. van de Mortel, K Marr, E Burmeister, H Koppe,C Ahern, R Walsh, S Tyler-Freer, D Ewald. Reducing avoidable admissions in rural community palliative care: a pilot study of care coordination by General Practice registrars.