End Of Life/ Palliative Care MODULE

QUALITY IMPROVEMENT TOOLKITAbout comorbidityChronic complex conditions cannot be cured. It is estimated that many people living with chroniccomplex conditions have more than one comorbidity. Comorbidity refers to the occurrence of two ormore diseases in a person at one time.1 in 4 (23%) Australians – 5.3 million people had two or more chronic conditions in 2014-2015.5The rate of comorbidity and the number of chronic diseases experienced increases with aged.Almost 1 in 3 (29%) people aged 65 and over reported having three or more chronic disease,compared with just 2.4% of those under 45.Comorbidity of selected chronic diseases by aged, 2014-15More information about comorbidities in Australia click hereComplex health needsComplexity is comorbity plus a range of other social, support, mental and other problemscombined. “Complex patients”: usually defined as patients with complex care needs, with acombination of multiple chronic conditions, mental health issues, medication-related problems, andsocial vulnerability.5Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. No.AUS199. Canberra AIHWBrisbane South PHN9END OF LIFE/PALLIATIVE CARE TOOLKIT

QUALITY IMPROVEMENT TOOLKITActivity 1 – Understanding your patient populationActivity 1.1 – Data collection from CAT4Complete the below table by collecting data from your CAT4 Data Extraction Tool. You mayalso refer to the Brisbane South PHN SA3 profile for your practice region to provide insightsinto population health priorities and compare this with your practice dataNote - Instructions on how to extract the data is available from the PenCS website or from themonthly Benchmarking report as provided by Brisbane South PHNThe aim of this activity is to collect data to determine the number of patients with a complex medicalconditionTotalnumberof activepatientsas perRACGPcriteria (3x visits in2 years)Description1.1aTotalnumberof activepatientsNumber of active ify active patients with at least 3 visits in the last 2 years1.1bNumber of active patients with Congestive heart fy all active patients with at least one chronic condition who are eligible for a Medication Review (follow instructions to the disease tab count)1.1cNumber of active patients with COPDhttps://help.pencs.com.au/display/CR/Identify all active patients with at least one chronic condition who are eligible for a Medication Review (follow instructions to the disease tab count)1.1dNumber of active patients with tia Patients and Carers1.1eNumber of active patients with chronic renal fy all active patients with at least one chronic condition who are eligible for a Medication Review (follow instructions to the disease tab count)1.1fNumber of active patients with y all active patients with at least one chronic condition who are eligible for a Medication Review (follow instructions to the disease tab count and select cancerconditions tab)1.1gNumber of active patients with a BMI pageId 47317101Brisbane South PHN10END OF LIFE/PALLIATIVE CARE TOOLKIT

QUALITY IMPROVEMENT TOOLKITPlease note: the RACGP defines active as 3 x visits in 2 years. This search criteria does not capturethose patients who may come in for screening every 2 years, or twice in 2 years e.g. flu vaccine,hence the option to look at all active patients.Reflection comments as a result of completing Activity 1.1:Practice name:Date:Team member:Activity 1.2 – Data collection from CAT4 – comorbiditiesComplete the below table by collecting data from your CAT4 Data Extraction Tool. You may alsorefer to the Brisbane South PHN SA3 profile for your practice region to provide insights intopopulation health priorities and compare this with your practice dataNote - Instructions on how to extract the data is available from the PenCS rbiditiesThe aim of this activity is to collect data to determine the number of patients with morethan 1 chronic medical conditionDescriptionTotal number1.2aNumber of active patients with 1 chronic condition1.2bNumber of active patients with 2 chronic conditions1.2cNumber of active patients with 3 chronic conditions1.2dNumber of active patients with 4 chronic conditions1.2eNumber of active patients with 4 chronic conditionsReflection comments as a result of completing Activity 1.2:Practice name:Date:Team member:Brisbane South PHN11END OF LIFE/PALLIATIVE CARE TOOLKIT

QUALITY IMPROVEMENT TOOLKITActivity 1.3 – Understanding your practice chronic disease populationThe aim of this activity is to increase your understanding of the active complex chronicdisease patient population.DescriptionAfter completing activity1.1 are there anyunexpected results withyour practice’s complexchronic disease patientpopulation?StatusAction to be taken Yes: see actions to betakenPlease explain: (for e.g. higherdiabetes population thanexpected, practice has a lowpopulation of people withcardiovascular disease) No: continue with activityHow will this information becommunicated to the practiceteam?Is your practice complexconditions similar to otherpractices in the BrisbaneSouth region (compareinformation fromBenchmark report)? Yes: continue withactivityOutline the differences – is itactive population, age groupdifferences, male/femalepopulations? No: see action to betakenHow will this information becommunicated to the practiceteam?After completing activity1.2 are there anyunexpected results withyour practice’scomorbidities population? Yes: see actions to betakenPlease explain: (for e.g. highnumber of people with 3 ormore chronic conditions) No: continue with activityHow will this information becommunicated to the practiceteam?Brisbane South PHN12END OF LIFE/PALLIATIVE CARE TOOLKIT

QUALITY IMPROVEMENT TOOLKITDescriptionAfter reviewing yourpatient chronic diseasepopulation, are there anychanges you would like toimplement in the practice,to help manage patients,over the next 12 months?StatusAction to be taken Yes, see actions to betaken to help set yougoals.Refer to the Model forImprovement (MFI) and theThinking part at the end of thisdocument. No, you have completedthis activity.Refer to the Doing part - PDSAof the Model for Improvement(MFI) to test and measure yourideas for success.Reflection comments as a result of completing Activity 1.3:Practice name:Date:Team member:Brisbane South PHN Chronic Disease toolkitsBrisbane South PHN have a number of chronic disease toolkits available that assist you and yourpractice to review specific conditions. These toolkits are designed to assist practices conduct qualityimprovement activities and set goals to see some improvements in patient health care.The toolkits are under continual development. Chronic disease topics include: AsthmaCardiovascular diseaseChronic Kidney diseaseCOPDDiabetesMental HealthOsteoporosisThe toolkits can be found hereBest practice tools to support the early identification of End of Lifepatients SPICT TOOL/ Surprise question:http://www.spict.org.uk/the-spict/MSH end of care nity.org/index.htmBrisbane South PHN13END OF LIFE/PALLIATIVE CARE TOOLKIT

QUALITY IMPROVEMENT TOOLKITActivity 2 - Important conversationsImportant conversations and chronic medical conditionsAs was outlined in chronic complex illness section, on statistics and comorbidities, it’s important tooffer to discuss early in the patient’s diagnosis or illness what is likely to occur in the future. Patientscan then plan their health care, time and life. The amount of information a particular patient willwant to hear will vary. Having a conversation just as someone is dying is much harder than startingearlier on.Important conversations for Non English speaking patientsFor patients who don’t speak English use the Appointment Reminder Translation Tool. This tool isavailable online and allows you to translate appointment details into your patient’s languageMore information in relation to interpreter services is in Brisbane South PHN Patient PopulationstoolkitAdvanced care planningAdvance care planning involves thinking and making choices now to guide the future of the patient’shealth care. It is also a process of them communicating their wishes. If they have strong beliefsabout what they want to happen in the future, it is particularly important for the patient to maketheir plans and wishes known now. This can be done by having a conversation and writing down theindividuals’ preferences.Advance care planning documents will only be used if a person is unable to make or communicatetheir decisions. People can change their mind, their plans, their Statement of Choices and legaldocuments at any time while they have decision-making capacity to do so.Advanced care planning formsThere are a number of forms available to assist people to communicate their decisions. These are:Statement of Choices Form A--for people who can make their own health caredecisions.Brisbane South PHN14END OF LIFE/PALLIATIVE CARE TOOLKIT

QUALITY IMPROVEMENT TOOLKITStatement of Choices Form B--for people who cannot make their own health caredecisions or who require support with decision-making.Statement of Choices Form A and B combined--for health care providers.Advance Health Directive form--for people who have decision-making capacity.Some patients may initiate discussions about the end of life with you and it is best that you areprepared to these unexpected questions from patients or relatives.Activity 2.1 – Activity – Advanced care documentationThe aim of this activity is to ensure relevant people in your practice know the importance ofend of life conversations and planningDescriptionDo all relevantpractice teammembers knowwhere to locateadvanced careplanningdocumentation?Brisbane South PHNStatus Yes:continuewith theactivity No: seeactions tobe takenAction to be takenForms can be located and-advance-care-planning-formsHow will this information be communicated to therelevant practice team members?15END OF LIFE/PALLIATIVE CARE TOOLKIT

QUALITY IMPROVEMENT TOOLKITDescriptionStatusDo any of thepractice teamrequiretraining/assistance on having end oflife conversations? Yes: seeactions tobe takenAfter reviewingyour end of lifeconversations/documentationprocesses, arethere any changesyou would like toimplement in thepractice, to helpmanage patients,over the next 12months? No:continuewith theactivity Yes, seeactions tobe takento helpset yougoals.Action to be takenTraining available at End of Life essentialsOrCaresearchHow will this information be communicated to thepractice team?Refer to the Model for Improvement (MFI) and theThinking part at the end of this document.Refer to the Doing part - PDSA of the Model forImprovement (MFI) to test and measure your ideas forsuccess. No, youhavecompleted thisactivity.Reflection comments as a result of completing Activity 2.1:Practice name:Date:Team member:Brisbane South PHN16END OF LIFE/PALLIATIVE CARE TOOLKIT

QUALITY IMPROVEMENT TOOLKITActivity 3 - Assistance for patients to live at homelongerLiving in Their Own HomeFor most people, living as independently as they can in their own home as they age is what theywant. But sometimes they might need some help with daily tasks that they can no longer manage.For example, they might need help with home maintenance, need aids and equipment, or theymight need help with tasks like dressing or preparing meals.Aged care services are designed with the aim of meeting changing needs of the older population. Myaged care is a service for people aged 65 years and older, available to assist with services. Thisincludes: Help at home Short term care in an aged care facility (respite) Permanent placement at an aged care facilityTo access these services, patients need to be assessed in their home. To book this assessment,contact MyAged CareNational Disability Insurance Scheme is a service available to Australians aged under 65. NDIS canprovide all people with disability with information and connections to services in their communitiessuch as doctors, sporting clubs, support groups, libraries and schools, as well as information aboutwhat support is provided by each state and territory government.To access this service please contact NDISQueensland Community Support SchemeThe Queensland Community Support Scheme (QCSS) provides supports to people who, with a smallamount of assistance, can maintain or regain their independence, continue living safely in theirhomes, and actively participate in their communities.To be eligible for the QCSS, patients need to be under 65 years old (or under 50 years old forAboriginal or Torres Strait Islander people) with: a disability (and are not eligible for the National Disability Insurance Scheme) chronic illness, mental health or other condition, or circumstances that impact ability to live independently in the community.To find out more information about QCSS please click hereActivities of daily living – Health AssessmentsUnder the Medicare Benefit Schedule (MBS), GPs are able to complete Health Assessments on allpatients aged 75 years and older, 55 years and older for Aboriginal and Torres Strait Islanderpatients. As part of this assessment GPs

Brisbane South PHN 7 END OF LIFE/PALLIATIVE CARE TOOLKIT Chronic Complex Illness Chronic diseases are long lasting, often life-limiting conditions that warrant end-of-life planning. End-of-life planning should occur before conditions progress to later stages where a person's ability to make end-of-life choices may be impeded.