Diseño Metodológico

The most common models of care which were implemented to facilitate partnerships to provide client-centred care were multidisciplinary case conferencing (also know as multidisciplinary team meetings) and care coordination, planning and management. Almost all projects had some element of inter-disciplinary engagement as part of its strategies, some of which were formalised through establishment of MDT meetings, others which were less structured such as the

incorporation of family conferences which included representatives of a range of disciplines participating.

Multidisciplinary case conferences

Around half the projects included the multidisciplinary or team meetings (MDT meetings) or case conferencing in their activities. For some, this was the primary focus of their project (e.g. NSW-7), for others, it was incorporated within a broader approach to care planning or end of life care

pathways. The elements for success appear to be consistent with what the literature tells us about partnerships – i.e. a good broker/facilitator, decision makers at the table, clear purpose, good processes and ongoing monitoring (Pope and Lewis, 2008). There seems to be good evidence emerging from the projects about the success of these processes, primarily in terms of the impacts on the providers involved. These include a greater understanding of the needs of clients,

improved relationships between providers and, particularly for generalist providers, improved understanding of palliative care issues. However, limited data were available on the impacts on clients themselves, primarily reflecting the difficulty of recruiting palliative patients to projects such

as this, and the ethical considerations around the use of what may be perceived as intrusive procedures required for evaluation purposes. Perceptions of providers were predominantly used as a proxy for client feedback, and these suggested that there were significant benefits for clients in the provision of more holistic and individualised, appropriately targeted care, and a reduction in the burden of care for carers.

Care planning for end of life

Approximately a third of all projects addressed end-of-life care planning, including the

development of pathways, skills, resources and advance care directives. These were primarily projects working in residential aged care. One of the main messages arising from the projects is an increased awareness by the sector that palliative care is core business for aged care facilities. This is now reflected in the funding arrangements, with the ACFI now including a complex care category which includes palliative care. Fundamental to these processes is the development of a care pathway, appropriate assessment, management and ongoing monitoring of care needs, particularly around pain relief.

Care pathways essentially provide a structured approach to providing individualised care for people who are dying. As Power explains, ‘their growing popularity reflects the emergence of new modes of governance in the context of a shift away from trust in professional expertise to

confidence in systems and auditable rules and procedures’ (Power, 1997, cited in Allen, 2009, p. 354). This focus on the individual, rather than the provider, is demonstrated through the use of evidence-based assessment tools to monitor and manage client needs and the inclusion of end of life decision making tools, such as advance care plans/directives (ACDs). The approach includes the participation of relevant disciplines in developing the care plan, as well as addressing spiritual and pastoral care matters. Clients and their carer/families are pivotal to this process and projects based in RACFs had a higher rate of client participation and/or representation in their case conference or care planning discussions than those undertaken in other contexts.

One of the major benefits of improved end-of-life care has been the ability of the client to remain in their home/aged care facility to die. A number of projects demonstrated reduced transfers to hospital for end-of-life symptom management, as well as improved use of pain assessment tools and appropriate medications. This suggests significant benefits for clients, as well as for providers and the health and aged care systems more generally. A number of projects reported increased feelings of confidence by staff in discussing end-of-life issues and providing end-of-life care; facilities also had reduced staff turnover, suggesting an impact on staff morale as well. A reduction in transfers to hospital and hospital stays is also likely to result in cost savings for the health system, although no project included calculations of cost savings in their evaluation reports. Competence and confidence of staff

Improvements in care planning and delivery has only been achieved through significant amount of education and training provided by projects, underpinned by the development of appropriate resources, protocols and processes. While the overall reach of educational activities is not clear from the project evaluation reports, we do know that this was a major part of their activities. The education and training was provided in both formal and informal processes, including structured education programs, competency-based training packages, in-service sessions and access to existing industry opportunities, as well as through mentoring, supervision and action learning through participation in MDT meetings and multidisciplinary forums.

The education and training was predominantly designed to enhance the implementation of new models of care or processes, such as multidisciplinary considerations, care planning approaches, assessment tools, and end of life care. The main target groups appeared to be staff of RACF and health services, and participants were provided with in-house learning opportunities or a location near by, and placements with specialist services. The outcome has been a significant

improvement in the capacity, competence, and confidence in staff providing care, which has been evidenced in the survey, focus group and audit results presented in the project reports. It can be deduced from these findings, that these educational efforts have resulted in improvements for

feedback in their evaluation strategies.

The importance of a skilled and confident workforce cannot be underestimated, particularly in high care residential aged care where the needs of residents are increasingly complex and end-of-life issues are a daily occurrence. The facilitation of care planning is a complex process, and staff are ‘not passive processors of different interests, but active mediators who displayed considerable skill in negotiating a space in which different frames of action could coexist by finding creative solutions in which they could be brought together while at the same time kept separate to contain the

potential to pollute’ (Allen, 2009). This suggests that a focus on supporting staff involved in care planning, through the provision of appropriate resources, training and systems, is critical to ensure sound outcomes for clients and residents around whose needs care is planned.

Targeting specific population groups

The sub-program provided the opportunity for a number of projects to focus on specific population groups, such as residents of aged care facilities, people with dementia, indigenous populations, children, adolescents and young adults, and people with chronic heart failure. There was a critical mass of projects targeting RACFs, and these were encouraged to network with each other,

sharing experience, knowledge, resources and, potentially, evaluation tools. Sector-wide issues were canvassed at national workshops, as well as through the development of an email list-server and projects were encouraged to participate in sector-specific initiatives such as conferences. While a significant number of resources, tools and processes have been developed for residential aged care staff, it was not possible to draw any conclusions about the overall impact on the sector from the evaluation findings, due to the variation in tools used, and data presented in the project final reports. As noted previously, it is clear that this sector is likely to require ongoing coordinated support, given the increasing recognition that the majority of residents will require end of life care. The specific needs of indigenous populations with end-stage renal disease were also addressed, resulting in the development of resources, strategies and processes that have been embedded into a new service across the region. Less successful were those resources developed for aboriginal carers, which remain in draft form due to decisions by project managers to focus on development of project initiatives, and not on the implementation.

Funding was also provided to develop care planning resources for children, adolescents, young adults and people with dementia and chronic heart disease. Together with the Aboriginal renal project, these have undertaken ground-breaking work to identify the evidence around best practice, engage with the broad range of client groups and stakeholders, and developing

strategies and resources that meet their various needs. The focus of these projects has primarily been developmental, and most will require ongoing support to further test and better articulate models of care that will meet the complex needs and service arrangements required for these population groups.