Dr Felice Borghmans1, Dr Archana Thayaparan1, Ms Fiona Mitchell1, Dr Cathy Corbett1, Dr Patrick Elliott1
1Alfred Health, Prahran, Australia
Biography:
Fiona Mitchell (O’Kane) is the Lead Clinician and Nurse Practitioner Candidate for the Palliative Assessment and Treatment Service (PATS) at Alfred Health, Melbourne. She has over 15 years of palliative care experience across inpatient, community, and ambulatory settings. Fiona’s work focuses on integrating specialist palliative care into hospital-substituted and community programs, workforce capacity building, and improving transitions of care for patients with complex and uncertain trajectories.
Abstract:
Aim:
Patients nearing the end of life (EOL) and receiving therapies intended to reverse deterioration or extend life (active treatment) often encounter barriers to timely access to community-based palliative care, resulting in a notable service gap. This project aimed to address this gap by integrating person-centred EOL care into the General Medicine Hospital in the Home (Gen Med HITH) program.
Methods:
A quality improvement approach was undertaken in collaboration with the Palliative Assessment and Treatment Service (PATS), General Medicine physicians with palliative care expertise, and the Complex Care Program (CCP). A community-based EOL care guideline was developed through consultation with clinical experts and stakeholders. PATS provided clinical mentorship, targeted education, specialist consultation, case-based teaching, debriefing to Gen Med HITH clinicians, and more. To enhance workforce capacity, all Gen Med HITH nurses completed training modules and workshops via the Commonwealth’s Program of Experience in the Palliative Approach (PEPA). Additionally, two nurse champions completed PEPA clinical placements, gaining practical experience alongside specialist palliative care clinicians. A “step-up, step-down” care model was implemented with the CCP to allow flexible adjustment of care intensity, particularly for patients receiving maximal therapy approaching EOL.
Results:
Since March 2023, seven patients have received integrated palliative care through the Gen Med HITH model. This approach effectively combined active treatment with comprehensive EOL care, respecting patients’ values and preferences and addressing palliative needs within the community. Post-implementation clinician surveys indicated that EOL care has become an accepted and well-understood component of practice, with staff reporting increased confidence, competence, and support.
Conclusion:
The growing prevalence of chronic disease and an ageing population necessitate adaptable EOL care delivery models. Integrating person-centred EOL care with active treatment in the HITH setting offers a sustainable and responsive approach that is aligned with contemporary healthcare demands and notions of value-based care.