Nurse Practitioner - Palliative Care

1. Nurse Practitioner - Palliative Care Karen Glaetzer Nurse Practitioner – Palliative Care Southern Adelaide Palliative Services Lecturer (B) – Flinders University

2. Southern Adelaide Palliative Services Regional Service – Population 330,000 Interdisciplinary team Clinical services, education and research 1200 referrals each year 380 current clients Seamless care model

3. Gaps identified in Service Provision • 30-40 families each year identified by SAPS whose needs were not adequately addressed • 82 referrals in 2002 under the age of 50 • Resource intensive • Utilised Multiple Service Providers • Complex psychosocial/psychological issues • Primary service providers with limited specialist palliative care skills • Limited availability of institution based resources

4. Triage Criteria • Chronic complex mental health history Long term mental health history who require ongoing assessment and treatment. • Multiple service providers More than 3 community service providers (GP, RDNS, Dom Care etc). • Complex symptom issues Patients who have significant, complex symptoms (physical or psychological), that require advanced skills to assess and manage. • Family dysfunction Families who have demonstrated difficulty coming to terms with the diagnosis/prognosis and where there is significant ongoing conflict • Complex individual caregiver issues Carers who have significant ongoing personal (physical or psychological) and who demonstrate difficulties adapting to the role of carer. NP referrals meet 2 of these criteria

5. Nurse Practitioner - Palliative Care Direct clinical service provision to palliative clients with overwhelmingly complex needs Coordination of case management, clinical problem solving, clinical decision making and advance care planning New patient OPD Clinics MND Clinic

6. Nurse Practitioner - Palliative Care Provision of education to patients, families and professional care providers Initiate and participate in research/projects Rural Mentor role Contributes to State and National Policy (State Plan)

8. OPD Clinics • Hospital Funded OPD – not medicarised • 3 patients – 1 hour appointments • Palliative Medicine Consultant holds concurrent review clinics • 15 - 20 minute overlap to assist in co-signing investigations or to provide scripts • Next appointment booked with Palliative Medicine Consultant

9. NP Role Evaluation

10. Journal • Maintained professional journal over the first 6 months of role • Recorded • Referral numbers from SAPS and reason for referral • Referral numbers from other health services and reason for referral • Planned and unplanned contacts • Input into care planning • Main activity – referral to others, consultation, prescription and ordering rates • Non-clinical activities • Research/projects • Education • Networking and higher level activities

11. Results – Snapshot data • Pre • Diary • Mean contacts per day = 3.14 • Number of NP criteria met = 2.25 • Mean satisfaction scores = 8.56/10 • Post • Diary • Mean contacts per day = 1.92 • Number of NP criteria met = 2.6 • Mean satisfaction scores = 9.16/10

12. Results – Staff questionnaire • Community team n=8/11 • Identifying impacts of NP • Possible reduced need for medical input • Streamline reviews and assessment • Reduce stress by reducing complexity of caseloads • Responsibilities • Varied opinion (lessened for some, others thought no change) • Consultant seen as supporting NP • Support • Most – NP as a support and resource, but varied opinion • Attitude to NP role • Can be viewed as privileged, choice of patients, protected time • Service issues • Who decides NP patients, how does triage work • How does follow-up get handled

13. Results – Journal

14. Results • Number referred to NP = 27 • Reason for referral • Complex symptoms = 8 • Family dysfunction = 5 • Multiple health providers = 4 • Complex mental health history = 2 • Caregiver issues = 8

15. Conclusions • Patient profile • By definition, more complex, more severe problems • Younger • Die at home • Difficult to evaluate • Small numbers • Limited timeframe • Methodological issues

16. Conclusions • Triage detects 1/3 patient numbers, other referrals after clinical assessment and as problems arise • Journal • Operates at local, regional, state and national level • Education • Policy • Research/project • Support and consultative • Extended practice reflected (within legislative limitations) • Case load reflects patients identified through triage criteria

17. Discussion • Outstanding features of the role • High numbers of rural contacts • Those services where SAPS is already aligned • Using the knowledge and skill base of NP • Maintains statewide MND clinic and support service • Local, regional, state and national involvement in • Education • Policy • Consultative and support roles

18. Possible Palliative Care NP Roles • Nurse led inpatient beds • Aged care/ Palliative care • Chronic disease/Palliative care • Consultative Clinics – hospital, community, RACF • Community

19. Contact Details Karen Glaetzer RN BN NP Cert Onc Cert Bioethics Grad Cert Health (Palliative Care) MNg (Nurse Practitioner) MRCNA Nurse Practitioner - Palliative Care Southern Adelaide Pallliative Services Repatriation General Hospital 700 Goodwood Rd Daw Park South Australia 5041 ph. 61 8 8275 1732 fax. 61 8 8277 4957 Email. Karen.glaetzer@health.sa.gov.au