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The SMART CLINIC

The SMART CLINIC. Symptom Management Assessment and Referral Team Clinic – a multi focused approach to a palliative care outpatient clinic Presenters: Dr Adrian Dabscheck –Palliative Medicine Consultant, Western Health Ms Fran Gore – Manager, Mercy Palliative Care Services.

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The SMART CLINIC

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  1. The SMART CLINIC Symptom Management Assessment and Referral Team Clinic – a multi focused approach to a palliative care outpatient clinic Presenters: Dr Adrian Dabscheck –Palliative Medicine Consultant, Western Health Ms Fran Gore – Manager, Mercy Palliative Care Services

  2. Our messages: -Identify the need – know your community -Persistence – be clear in what you want -Patience - lots of it!

  3. How it all began Western Health and Mercy Palliative Care share a long standing relationship. Outreach programme commenced in 2008 resulting in improved patient outcomes. ↑ symptom management ↑ deaths at home ↑ direct admission to inpatient palliative care units Achieving patient goals of care Access to hospital pharmacy for non PBS medications

  4. How it all began – identifying the need Both Western Health and Mercy Palliative Care had recognised that a group of patients were ‘slipping’ through the gaps. Oncology patients seen exclusively as outpatients often had symptom issues that could potentially benefit from palliative care input – either consult service or community palliative care. These patients are often not referred to palliative care until admitted as an inpatient when disease/symptoms become problematic. Late referral to community palliative care, or not referred at all and family missing out on bereavement support. Avoidable presentations to ED or multiple hospital admissions. Often multiple medication issues

  5. How it all began There was a perception by Cancer Services at Western Health that many of the Oncology patients would gain from earlier Palliative Care in put. The success of the Outreach program gave Western Health the confidence to build on that and work further to remove the institutional barriers between Hospital and Community care. Appointment of full time Palliative Medicine Consultant to WH. Had experience of working in an outpatient palliative care with pharmacy input. Inclusion of community palliative care would enhance patient outcomes

  6. Where to start? – be clear in what you want Main challenges: Funding Space Bureaucracy

  7. Funding Application for grant funding to Western and Central Melbourne Integrated Cancer Service – successful. Funding for 12 months: Project Officer Clerical and nursing support for outpatient clinic Pharmacy support for clinic Need to prove need and sustainability for this period Only for patient with a malignant diagnosis for the period of the project.

  8. Commencement Recruitment and appointment of Project Officer Feb 2012 – Feb 2013 Review of clinic space in outpatient department – conversion to MBS clinics – more about that later! Application to WH Ethics committee for approval as a Quality Assurance programme Project Committee established comprising key stakeholders – internal and external and a consumer representative

  9. Background information Number of unscheduled appointments for palliative care consultants in Day Oncology – 92 informal palliative medicine consults in 12 month period Outpatient Department – 74 informal palliative care medicine consults in Gen Oncology in 12 month period Back ground survey conducted: What amount of time do medical staff time currently spent on symptom management and end of life issues? – survey of consultants and registrars from all tumour groups. Could a symptom management clinic with a palliative approach assist with this?

  10. Background information 83% response rate from 70 medical staff from tumour streams at Western Health 74% of these were consultant medical staff 26% were Registrars All were potential referers

  11. Background information Results :

  12. Background information 91% stated they would refer to a clinic set up specifically for symptom control issues Benefits of such a clinic were rated by the respondents in the following order: Improved symptom management Improved pain control Facilitating community palliative care referral Facilitating discussion of end of life issues and patient goals of care Streamlining specialised care from general ( oncology) clinics

  13. Background information Supported anecdotal evidence of need Survey served as an awareness raising exercise All tumour groups supportive of clinic “How soon can you start!” Divisional Director and Manager supportive

  14. Commencement Project committee and working groups established Clinical Evaluation = sustainability Pharmacy

  15. Commencement First clinic held May 31st - along side colorectal clinic Referrals slow at first However, benefits apparent from the onset Provision of emergency injectable medications Linking to community palliative care sooner rather than later • 24 hour number Bereavement support

  16. Challenges and learnings - patience Working within an MBS clinic environment Income generation Medication dispensing Clinic space!!! Ensuring data collection to prove sustainability • Data entry – who does • Software Availability of Pharmacy staff – no backfill for leave Change of time/day and location of clinic

  17. Results to date:

  18. Feedback Patient survey developed based on the UK Picker Institute examining patient and carer experience around the domains of: Respect for patient centred values Coordination and integration of care Information, communication and education Physical comfort Emotional support Welcoming the involvement of family Transition and continuity Access to care

  19. What do patients say? Number of surveys to date: 8 Themes Positive experience of palliative care Better understanding of medications Family/carer involvement Identification of palliative care as part of treating team

  20. Challenges to date Pharmacy issues related to MBS Model. Different model than we planned for as it does not run in parallel with Oncology OP, due to lack of physical space. The usual teething problems one would anticipate setting up a new clinic in a very busy public hospital, but there has been an amazing amount of good will to assist clinics establishment.

  21. Progressing the SMART Model New Symptom Control Clinic at Sunshine Radiotherapy Centre. Palliative Medicine works in parallel with Radiation Oncology. Successful from an Institutional perspective and from patient perspective as shown by survey results. Working towards using SMART Clinic model at Sunshine Radiotherapy Centre.

  22. Acknowledgements WH Divisional Director – Ms Jenny Walsh WH Director of Cancer Services– Prof Michael Green WH Cancer Services Manager – Ms Adele Mollo WH Director Palliative Care – Dr Maria Coperchini Mercy Health Project Officer-Kathy Hendry WCMICS as project funding body

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