Hospice Waikato Rural Outreach Service: Working in Partnership

Jenni Bell RN Emma Furlonger-Jones RN

Joan Keucke RNCatherine Wolicki RN

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.

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”

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

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

• Oncology and other specialist services at Waikato Hospital

• GP Practices

• District Nurses

• Residential Care Facilities

• Self-referral

• Out of region

How we receive referrals

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

• Photo

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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

Our Challenge

• Beginning of 2014 we set ourselves the task of reviewing the assessment process and documentation we use

• Purpose: Inform ourselves and othersClarify and validate the roleProvide a framework for the work we do Highlight the work and make it more visibleEnsure the service is effective and sustainable

• Where to start?........looked at the assessment tools we already had to work with ie: on PalCare

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

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?

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?

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?

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?

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)

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)

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?

Cultural/Religious/Spiritual

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?

Expectations of the Service

Awareness

Concurrent issues

Relationships

Social Supports

Wishes and Goals

Spiritual Beliefs

Cultural/Spiritual Needs

Expectations

“The very best of Hospice care considers these aspects of well-being and tailors the care that it provides to match the

individual”

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

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?

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

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

“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)

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)