An integrated approach to palliative care for frail older people living in the community: exploring a model of multidisciplinary collaboration.

Abstract

Background: Australia has an ageing population which face an increasing prevalence of chronichealth conditions and comorbidities in later life. The population is placing increased pressure on theAustralian healthcare system. Frailty is also likely to rise with an increase in the number of olderAustralians. Frailty is predictive of disability, hospitalisation and death. Palliative care is anapproach that improves the quality of life of patients and their families when the patient isdiagnosed with a life-limiting illness. Palliative care focuses on preventing and relieving symptomsassociated with a patient’s illness, such as pain, physical symptoms, psychosocial and spiritualsupport. As frailty is predictive of death, then it follows that frail patients should be identified andoffered palliative care when appropriate. Palliative care is provided in a multitude of settings inAustralia including: - hospital, hospice, aged care, and home. However, there is a finite number ofspecialist palliative care services available. Recently, researchers have been investigating theeffectiveness of shared care models and models that integrate primary care (general practitioner)and secondary care (specialist services) to improve patient care and quality of life. However, thesemodels have not been developed nor assessed for a frail older population. To investigate the use ofthis method for an increasingly aged population, this thesis refined and tested the feasibility andacceptability of a model of integrated palliative care for frail older people in the community.Method: A two-phase sequential mixed methods design was used. As part of the literature review,a systematic review was conducted and a model of integrated palliative care, engaging GPs andspecialist secondary services was identified. Phase 1 was a qualitative study, exploring healthprofessionals’ experiences and perceptions of caring for frail older people, of providing palliativecare to patients. It also sought the health professionals’ views of the model of integrated palliativecare that was identified through the literature. The health care professionals were recruited using amix of purposive and snowball sampling, and comprised of six focus groups involving 12 GPs, fourgeriatricians, seven palliative specialists, six nurses, and seven allied health professionals. Datawere analysed thematically using a framework method. Based on these results, the model ofintegrated palliative care for frail older people was refined.Phase 2 used a mixed-methods pilot study with a qualitative and a quantitative component, to assessthe feasibility and acceptability of the model of integrated palliative care for frail older peopleliving in the community. This used a pre-post design. The primary aim of the quantitative component of phase 2 was to provide a preliminary estimate ofthe effect of the model of care on hospital admissions. To this end, patients and/or carers completedquestionnaires at baseline and at one month and three months post-intervention.The aim of the qualitative component of phase 2 was to explore the experience of participants of themodel of care. Semi-structured interviews were conducted with two patients, five carers, twointerviews with the patient and carer together, six GPs, three geriatricians, two nurses and fourallied health professionals who participated in the model of care. A question guide was developedto ensure consistency. Data were analysed thematically using a framework method.The data from both the quantitative and qualitative components were integrated to provide acomprehensive analysis of the data to assess the feasibility and acceptability of the model ofintegrated palliative care for frail older people.Results: A systematic review identified that integrated multidisciplinary case conference had themost robust evidence and was the most pragmatic form of primary secondary integration. This wasthe basis of the model of end-of-life care that was examined during the study.Phase 1 of the study identified four major themes that indicate the complexity of working with frailolder people and the challenges of identifying and discussing issues related to palliative care:complex trajectory, constructing the appropriate frame, inclusivity and constraining boundaries.Each of these themes contributed to the refinement of the model identified by the systematic review.Phase 2 of the study indicated that the patients involved in the pilot study experienced improvedmental wellbeing. Carers also experienced improvement in physical and mental wellbeing.Moreover, there was a decrease in the patients’ hospital admissions, average days in hospital andemergency department visits. With a small sample size and a pre-post design, these findings cannotbe extrapolated or attributed to the model. The model of care was found to be acceptable. However,funding barriers and staff workload pressures reduced the feasibility of the model.Conclusions: The model of integrated palliative care was acceptable and may provide benefit tofrail older patients and their families and would likely reduce hospitalisations. However, workloadand paucity of funding create barriers to implementation and reduce the feasibility of the model inthe current system. Specific funding allocations to support the model would need to be implementedto ensure success.