Ms Esther Wen1, Ms Mika Musgrave-Takeda1,2, Ms Rachel Everitee1,2, Ms Isabella Hall1,2, Mr. Neil Robinson1,2, Ms Laura Bird1,2, Ms Jade Hudson1,2, Ms Ealine Trinh1,2, Mr Scott Reeves1,2, Mr. T Dale4, Mr. C Oarker3, Mr Peter Poon1,2
1Supportive and Palliative Care Unit, Monash Health, Clayton, Australia, 2School of Clinical Sciences, Monash University, Clayton, Australia, 3School of Public Health and Preventive Medicine, Monash University, Clayton, Australia, 4Regis Healthcare Limited, Australia
Biography:
Esther Wen is a Clinical Nurse Consultant and researcher in the Supportive and Palliative Care Unit at Monash Health, Australia. With a strong commitment to improving end-of-life care, Esther integrates clinical expertise with academic research to enhance patient outcomes and support families during critical transitions. Her work focuses on innovative models of care, interdisciplinary collaboration, and culturally sensitive approaches, particularly for diverse communities. Esther contributes to Monash Health’s education and research initiatives in partnership with Monash University, helping shape the future of palliative care through evidence-based practice and compassionate leadership.
Abstract:
Background:
Hospital presentations are common among aged care residents nearing the end of life, contributing to distress and additional healthcare burdens. Despite over 90% of these residents benefiting from a palliative approach, barriers like fragmented care, limited specialist access, and delayed deterioration recognition persist. To address these gaps, a specialist palliative care Clinical Nurse Consultant (CNC) role was integrated into a Residential In-Reach (RIR) service of a major tertiary hospital, aiming to improve palliative care access and timeliness for aged care residents.
Aim:
This study aims to evaluate the impact of embedding a specialist palliative care CNC model within RIR services across a large metropolitan area.
Methods:
A mixed-methods evaluation, guided by the Consolidated Framework for Implementation Research (CFIR), was conducted over eight months (June 2024–March 2025). Data were collected on referral source, resident demographics, clinical needs, time to first contact, and interventions provided. Post-implementation surveys of RIR clinicians, residential aged care staff, and general practitioners assessed the perceived impact, utility, and acceptability of the model.
Results:
Across 84 facilities, the CNC conducted 198 clinical interactions. Residents had a median age of 86 years, with 83% presenting non-oncological conditions. The most common interventions included symptom management (43%) and staff education (15%). Referrals primarily came from Emergency Departments (49%), with 64.6% of residents seen within 24 hours. Seventy-three percent were discharged back to facility care, and 92% of deaths occurred in residents’ usual facilities. Among surveyed staff (n=24), over 90% agreed that the CNC improved pain and symptom management, early palliative care engagement, and access to specialist services. Over 85% agreed it enhanced end-of-life communication and Goals-of-Care discussions.
Conclusion:
The embedded CNC model within RIR services is feasible, rapidly adopted, and highly valued. It enhances access, streamlines referral pathways, and strengthens integrated, resident-centered palliative care across aged care settings.