‘Just in Case’ Action Plans (Palliative & End-of-Life Care) Information & “How To” Guide Background There are gaps in palliative care services locally, both in and out of office hours. General Practices manage a significant volume of patients who are not under hospice. When a sudden change in a palliative patient’s condition occurs, accessing appropriate care can be difficult which in turn leads to more distress and suffering, and often unnecessary hospital admissions. Over the last two years (July 2017 - June 2019) there were 812 acute palliative admissions to Tauranga Emergency Department from the BOP (528 from WBOP). Of these admissions just 18% were referred by a GP and 74% were self (or family) referred. The majority of presentations took place during working hours, were non-cancer related and involved a steep increase in volumes from the age of 69 years. The demand for acute palliative care is expected to increase by 51% over 20 years as population growth increases, especially of the older adult (Ministry of Health, 2017). According to recent data, dementia represents the highest overall proportion of deaths in the Bay of Plenty (28.4%), and is the highest trajectory group for NZ Europeans and other Europeans. For Maori, cancer represents the most deaths (29.9%), for Pacific peoples the Need and Maximum Needs group (other palliative conditions including younger disability groups) at 33.4%, for Asian and MELAA, cancer, at 29.4%. Seventy-one per cent (71%) of all deaths have both public hospital and ED events in the last year of life (Trajectories Project, 2015).
Service description This initiative enables inter-provider support to be available to palliative care patients in the community. General Practice teams are invited to complete Action Plans with prescriptions for their palliative patients. Funding will be provided for each plan that is submitted and shared. These plans would enable other providers such as St John to respond to the patient when concerns arise, follow the plan and administer medications. The episode of care may involve end-of-life care, an exacerbation of a chronic condition, or an assessment towards a reversible cause. The plans would enable patients to be managed at home (or care facility) whenever possible and appropriate. If further assessment or treatment were indicated, a doctor’s assessment may be necessary. Whether this was through the General Practice team, Accident & Healthcare or the Emergency Department, consideration would be made for the most appropriate option. A discussion with the GP whenever possible would assist St John personnel in making this decision. The Action Plan would be supported by good conversations taking place with the patient/ family and whanau. Listening to the patient’s wishes, discussing realities, and writing a plan which reflects both is likely to improve the experience of care when a change occurs. The Serious Illness Conversation guide is a useful tool to support this (see resources).
WBOP PHO, RM, December 2019
Eligibility and consideration criteria Anyone considered palliative, as indicated by one of the following triggers that suggest that patients are nearing the end of life: 1. The Surprise Question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days’? (less than 12 months) 2. General indicators of decline - deterioration, increasing need or choice for no further active care 3. Specific clinical indicators related to certain conditions
Consider a ‘Just in Case’ Action Plan for: • aged residential care patients • dementia patients • chronic disease patients • cancer patients • congenital disease patients
Benefits For General Practice: • Reduce future stress & worry less about your palliative patients • Prepare to meet a new RNZCGP Foundation Cornerstone indicator on Continuity of Care: ‘Ensure patients with palliative care needs can always access their primary provider or an informed clinician” (currently in draft form) • Plan emphasises General Practice as the primary provider • Funding per plan, which is flexible to cover GP, NP, PN and administration time, depending on how the individual practices operate. For patients/ whanau, families: • wishes documented ahead of a change • helps patients and families to cope & remain at home • more seamless care • better control of pain & other symptoms • free to the patient (consultation & Action Plan) • reduces futile care - more tests and procedures don’t always equal better care
Hope for the best, prepare for the worst It’s just in case… We only have one chance to get it right
WBOP PHO, RM, December 2019
Process •
We expect different providers to manage completion of these Action Plans in different ways. A suggestion would be to invite eligible patients to return in the next 2-4 weeks for a double (free) funded appointment where the GP will write a Just in Case Action plan with them. Whanau/family and support persons could be invited also. Or the wishes of the Action Plan discussed with them later (or next visit).
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The Just in Case Action Plan & Prescription gets filled out with the patient present, by the GP or NP (prescriber). Option for Practice Nurse to start the plan with patient, with completion & sign-off by GP.
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The ‘Just in Case’ Action Plan template (& resources) can be found on the PHO Portal. The template is initially being released in a manual form (to later become an electronic form). Figure: Page 1 and 5 of JIC Action Plan template (see appendix)
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Just in Case Action Plans can be completed as: i. Word documents, typed onto computer. Then saved, printed, signed and scanned. OR ii. Printed and handwritten on paper form. Then signed and scanned.
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For continuity and coordination of care, please consider providing your personal phone number at the ‘Contact note’ section (top right side) of Action Plan. Alternatively, you may wish to write “as per Hospital switchboard”, for St John to access you this way. You can advise the Hospital of your number on 07 579 8000.
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Feedback will allow evaluation and improvement to take place. Both from a clinician perspective and patient/ whanau focus. Please could: i. the relevant clinician(s) involved complete the feedback form provided AND ii. the clinician indicate (on the same form) whether the patient/whanau (and you) would be happy for the PHO to contact the family for feedback, or if your Practice would like to do so. Please send feedback form with the invoice to the PHO
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Request upload of the ‘Just in Case’ Action Plan to CHIP. See next page. Please also ensure: i. patient details are clear on the form and prescription ii. you upload all six sides of the Action Plan, even in the exception that a page isn’t filled out (clarity for the clinician accessing Action Plan) Medical Records cannot be held responsible for clinical aspects.
WBOP PHO, RM, December 2019
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Upload (all six sides of the Action Plan) to Health Records/ CHIP via BPAC (see pictures below).
WBOP PHO, RM, December 2019
Payment Manual invoice of $160 (incl. GST) per completed uploaded Action Plan. Please include on your invoice: • GP name, NHI, date of consultation & clinician feedback (form provided) Send to General Practice Liaison Team: GPSadmin@wboppho.org.nz
Evaluation and Improvement In order to meet the aims and objectives of the programme and make necessary improvements, the PHO will audit the outcomes of the initiative. The PHO request assistance from providers in passing on relevant information. • St John will send you direct notification of patients they attend who have a Just-in-Case plan The PHO requests from providers that: • The clinician completing Action Plan completes a feedback form (return with your invoice) • If one of your Action Plans is utilised, please notify the PHO (email or phone Ruth McChesney, see below) • The PHO will analyse data and provide feedback to St John.
Additional Information Anticipatory Medications St John personnel will be offered training in subcutaneous injection administration for these purposes. If anything falls outside the scope of a junior crew member, they can call for the back-up of a senior crew. St John decided in 2019 to phase out the use of morphine nationally and to replace it with fentanyl. Qualified crew members can still administer morphine (or other medications outside of their usual procedures) provided there is a legal prescription and a dispensed supply of the same. Please consider therefore whether you wish to dispense morphine for injection and/ or have fentanyl as an alternative (see prescription template). The PHO will assist in supplying St John with the other medications listed on the prescription template, therefore reducing anticipatory drug wastage. Other Costs An annual St John membership costs less than one standard call-out and covers multiple call-outs over the year. For eligible patients the cost of the subscription can be covered by the WINZ disability allowance. https://www.stjohn.org.nz/Support-us/Join-our-Supporter-Scheme/ https://www.workandincome.govt.nz/providers/health-and-disability-practitioners/guides/disability-allowance-allowablecosts.html#null
Resources Available on PHO Portal, and appendix below. Contact details: Phone: (07) 577 3267 Email: GPSadmin@wboppho.org.nz (invoicing) OR ruthm@wboppho.org.nz (feedback, operational & clinical questions)
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Care after death (optional form) The process for completing the necessary paperwork after death can be unduly stressful in some circumstances such as out-of-hours and where there are cultural requirements to do things within defined time frames. Where you have a patient for whom death within a short time would not be unexpected, consider completing the letter below to: • reassure the funeral directors that (as long as no concerns are expressed by anyone at the time of death) you would be happy to provide a death certificate (and cremation form) at the first opportunity, likely to be the next working day and • document the anticipated cause of death (e.g. metastatic lung cancer) so that if another health professional is called upon to do the death certificate they can clearly see what you thought the cause of death would be Complete the following section, changing any wording as necessary. To the funeral directors ______________________________________ In the event that ____________________________ passes away outside of general practice opening hours, I or a colleague will be able to provide a death certificate (and cremation form if required) as soon as our practice re-opens. The anticipated cause of death is: 1(a)._____________________________________________________________ 1(b).____________________________________________________________ 2.____________________________________________________________
Signed (Doctor or Nurse Practitioner): _________________________ Print name: ______________________ Designation: _____________________ Practice: ________________________
Date: ______________________
WBOP PHO, RM, December 2019