B4 - Community Practice
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Waikato rural palliative care services: Working in partnership Emma Furlonger-Jones, Jenni Bell, Joan Keucke, Catherine Wolicki
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B4 - Community Practice
- 1. Hospice Waikato Rural Outreach Service: Working in Partnership Jenni Bell RN Emma Furlonger-Jones RN Joan Keucke RN Catherine Wolicki RN
- 2. Rural Outreach Service ….is an inter-disciplinary model of care providing specialised medical, nursing and family support, in collaboration with District Nurses, General Practitioners and other health providers.
- 5. History of the Service A collaborative nursing role was established at Hospice Waikato in November 2003, in response to contractual obligations and the organisation’s commitment to the vision described in the New Zealand Palliative Care Strategy (2001) “All people who are dying and their family/whanau who could benefit from palliative care have timely access to quality palliative care services that are culturally appropriate and are provided in a co-ordinated way”
- 6. History of the Service The service originally consisted of a Registered Nurse and a Co-ordinator and provided: • Emotional support for patients and families • Access to social work services • Equipment • Inpatient beds in a local Rest Home • Grief and bereavement counselling • Access to support for children where a family member has a life-limiting or life threatening illness
- 7. Facts and Figures • Rural Outreach services received 464 new referrals in the 12 months to 30th June 2014 (This represents approximately half of all referrals to Hospice Waikato) • The outreach nursing team carried out 2,270 home visits • Travelled approximately 3000 kms each per month
- 8. How we receive referrals • Oncology and other specialist services at Waikato Hospital • GP Practices • District Nurses • Residential Care Facilities • Self-referral • Out of region
- 9. Working in Partnership • As Palliative Care Nurses in the Rural Outreach Team our focus is on psychosocial support • We work closely with other healthcare professionals in the local communities • Most importantly we are working in partnership with our patients and whanau • Our Hospice Family Services team may work alongside us, adding to this partnership
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- 12. Our Challenge How do we? • Capture this psychosocial information and document/convey it to others • Identify how it is for people – their main issues • Identify clinical issues while focusing on impact on quality of life and not management of these • Build a picture of how people are, “where they are at” • Meet the professional and organisational requirements in terms of documentation • Remain free to practice in the way we choose
- 13. Our Challenge • Beginning of 2014 we set ourselves the task of reviewing the assessment process and documentation we use • Purpose: Inform ourselves and others Clarify and validate the role Provide a framework for the work we do Highlight the work and make it more visible Ensure the service is effective and sustainable • Where to start?........looked at the assessment tools we already had to work with ie: on PalCare
- 14. PalCare and SES • Hospice Waikato is one of 19 in NZ using PalCare • Potential assessment tools already decided upon • Social/Emotional/Spiritual (SES) chosen as most relevant to our work • Not validated but peer reviewed by Hospices in Australia • 8 domains – chosen as a combination of areas where important psychosocial information can be recorded
- 15. Awareness of Diagnosis Awareness of Diagnosis/Illness/Death Circumstances around diagnosis Physical Symptoms Treatment plan Awareness of prognosis /palliative care Communication style When/how diagnosed? What led up to this? What has been happening since? Thoughts/feelings around this? Current problems? Symptoms experienced? Past /present treatments? Hospital appointments? What do you understand about your illness/treatment? What do you want/not want to know? Do you mind talking about /prefer not to talk about your illness?
- 16. Concurrent Crisis and Past Issues Concurrent Crises or Past Issues Co-morbidities Family Issues Life events Other losses or concerns Other health worries? Problems with hearing/eyesight? Is your family close/not close/supportive? Do you have concerns about family members? Are there special events/anniversaries/occasions coming up? Do you have financial worries?/concerns about where you live? Are you working/unable to work?
- 17. Relationships Relationships (GENOGRAM)) Family Close friends Who do you live with? Who else is at home? Who else visits/supports you/lives locally? What is your role in the family? How has this changed? Where do you get other support from? Who else do you talk to? Who else is supporting your husband/wife/children etc? Have relationships changed as a result of your health problems?
- 18. Social Supports Social Supports Friends Community groups Volunteers General support etc. Who else do you have to call on if needed? Do you attend/belong to: support group/ church group/craft or music group? What else would you like to be involved with? Who else visits/helps with shopping/housework etc? What other areas of your life do you have help with/would like help with?
- 19. Wishes and Goals Wishes and goals “Milestones”/Anniversaries Short term goals End of Life care What do you hope / plan/ need to do in this time? Special occasions to look forward to? Have you discussed end of life care? (funeral/Will/POA/resuscitation) Where would you like to spend your last few weeks/days? Where would you like to die? Who would you like around you? Fears/concerns? (Use ACP documents)
- 20. Spiritual Beliefs Spiritual Beliefs Beliefs/values Meaning/purpose Religion What is important to you? What gives your life meaning/purpose? Values/beliefs around end of life? What gives you strength/courage/peace? Who do you talk to about this? Do you belong to a church/faith community? How is this helpful? Has your illness helped/hindered your ability to connect with these things? (Use HOPE questions)
- 21. Cultural/Religious/Spiritual Are there any specific cultural/religious/ spiritual needs? Needs Practices What do I need to know? Are there things you are needing to do/not been able to do/not comfortable with? How can they happen? Rituals/practices to be observed prior to/at death (cultural/religious/within family) Who would you like/needs to be present? Who is aware of this?
- 22. Expectations of the Service Expectation of support service Knowledge/expectations Fears and concerns Other services involved? What do you know about hospice? Previous experience/involvement? What would you like/not like? What are you most concerned/worried about at this time?
- 23. Awareness Cultural/Spiritual Needs Concurrent issues Relationships Social Supports Wishes and Goals Spiritual Beliefs Expectations
- 24. “The very best of Hospice care considers these aspects of well-being and tailors the care that it provides to match the individual”
- 25. Questions and Challenges • Practical challenges of using SES ie: reviewing and updating • Overlapping of issues into several domains • Ethical concerns of including family • Process is one of relationship-building and not outcome driven • Time
- 26. Questions and Challenges • Do we have the necessary knowledge and skills? • Are we prepared and supported to do the work? • Are we practicing in a culturally safe way? • Are we assuming our patients are willing and able to engage in in-depth conversations about the psychosocial aspects of their care? • How do we measure the value of our work? Implications for funding?
- 27. Our Learning • Valuable process in demonstrating the scope of the work and how much involved • Potential to highlight what we do know/don’t know/need to know • Encourages us to look at current and future partnerships to help us meet increasingly complex needs and manage workloads e.g.: Te Korowai, Te Kohao Health, Hauraki PHO, Mental health services, Cancer Society, LBC
- 28. To Summarise • “Work in progress” – ongoing process of reviewing and improving the work we do and how it is recorded • Continue to look for new tools to strengthen assessment process • Be open to developing new partnerships • Continue to use a flexible, patient/whanau focused, enquiring approach, gathering information using a narrative style of assessment
- 29. “By working in partnership, hospices augment their own skills and services to meet the needs of those in their care. They can learn much from colleagues in other specialties and can provide more holistic and seamless care when they work closely together to support individuals with multiple needs” (Help the Hospices Commission into the Future of Hospice Care, 2013)
- 30. References • Anandarajah, G. & Hight, E. (2001) Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment. Am. Fam. Physician, 63 (1), 81-89 • Fitzsimmons,D; Ahmedzai, S. (2004) Approaches to Assessment in Palliative Care. In S. Payne, J. Seymour & C. Ingleton (eds) Palliative Care Nursing: Principles and Evidence for Practice (pp163-185) Berkshire, OUP • Help the Hospices Commission into the Future of Hospice Care. (2013) Future ambitions for hospice care: our mission and our opportunity. The final report of the Commission into the Future of Hospice Care. UK • Gardener,D. (2005) Ten Lessons in Collaboration. Online Journal of Issues in Nursing, 10 (1)
Hinweis der Redaktion
- Given the theme of conference we are here to talk about our service and how we work in partnership
- The team includes a NP, CNS, four palliative care nurses and a visiting consultant doctor. Taking hospice out to rural areas
- We get to travel around the Waikato and to some of the best beaches in NZ
- Hospice Waikato services the largest single DHB geographical region of any Hospice in NZ. One of the highest rural populations. Area divided into four and shared between four of us
- As the needs have grown the service has evolved. It continues to do so but has stuck close to the original vision/purpose of the service from 2003
- 2013-2014 financial year: WDHB 72%, GPs 18%, Rest Homes 2%, Family or other health services 8% Complement, not replace, these services. Not taking over….. Come alongside and work in partnership
- Hospice care is a choice Meet patients and families, introduce self and Hospice services Invite them to share their story, identify their concerns, work out how and where these can be best addressed Approach is patient/family focused. Each RN will have their own style of working. Aim is to build trust, understanding, gather information to inform, not determine end point Resources needed are time, energy and petrol! Good communication and observation skills. Of course other Hospice nurses doing this work but this is our core business. Point of difference = time
- Examples?
- Examples?
- In doing this work the challenge is how we….
- Referrals increasing, frequent questions “What do you do ?”, some confusion around role Without a clinical task what do we do?
- Who else uses this? SES: Where had it come from? Research/guidelines around use? – a starting point to be expanded upon? So this is what we did……
- Looked at each domain in turn. This is where we have got to Discussed under which heading certain information could be included – some overlapping but offers guidelines Identifies/records clinical information but full assessment by GP & DNs – not wanting to repeat or confuse role Prompts, but avoid asking a series of questions, to explore/open up discussion Gain idea of the journey so far Identify tools which may add to/enhance assessment eg: ECOG
- What else is going on for them? Health and otherwise What else do people identify as problems/concerns in their life?
- Who else is around? Who else may need support? What other sources of support can be accessed? Genogram
- Other sources of support outside of family/locally? Who else could be helpful?
- Hopes/fears “Bucket list” Wishes and goals around ongoing health and well-being as well as end of life care Use ACP?
- Perhaps the most difficult one Nurses traditionally poorly prepared How do we raise the subject/explore with patients? Spirituality may be expressed through religion but not always Tool: HOPE questions = teaching tool for med. Students to begin process of spiritual assessment, covers basic area of inquiry ie: organised religion, practices, sources of comfort
- Explored further Identifying important factors for staff to be aware of.
- Expectations/ hopes/fears? Reassure/ dispel myths.
- Therefore SES used to reflect our work, identify issues and needs according to patient and from there a plan of care made in partnership with pt. ?Who else is involved or could be We think of our SES as a 3D framework, like a tree, on which to organise and record/ “hang” information. Uses patient narratives Something which is living and growing, moving through the seasons, feeding from its environment etc A dynamic process, being added to, not a “snapshot” Rather than a series of boxes containing/restricting the information
- May look something like this….. Quote from Help the Hospices Commission into the Future of Hospice Care (2013) Plan of care comes from patient/family frame of reference ie: planned in partnership
- Some of the questions raised.
- Also highlighted: Areas to upskill, when to refer on Supervision, Family Services team Adhere to Treaty of Waitangi 3P’s, practice similar to Te Whare Tapa Wha model – same philosophy different words
- Listen and learn from others as well as… Included Family Services Team in our meetings, recently completed F of S programme, connecting with new services …… Te Korowai = Kaupapa Maori Services for the community/Oranga Wairua Hauraki PHO = Pilot programme – Long term conditions Whanau Ora Programme Avoid working in “silos”
- Our conclusions….