Abstract
Aims and Objectives: To develop an understanding of the implementation of the Community-Criteria for Screening and Triaging to Appropriate aLternative care (C-CriSTAL) initiative in primary healthcare setting in South Western Sydney (SWS). Background: C-CriSTAL is a prognostic assessment tool that identifies elderly patients at the end-of-life (EOL), quantifies the risk of imminent death and facilitates discussion on care preferences. A General Practice co-designed initiative C-CriSTAL was developed which included an advance care planning implementation package (ACPIP) with the components of early detection, identification of EOL care needs and communication with the patient in primary healthcare setting. Design: Qualitative study. Methods: Semi-structured interviews were conducted with purposive sample of Executive Sponsor and members of the Clinical Reference Group including representatives from a Local Health District, C-CriSTAL Project Team, a Primary Health Network, Consumer, General Practitioners. The Interviews were recorded, transcribed verbatim and analysed qualitatively by means of a thematic analysis. Results: A total of 12 interviews were conducted. Thematic analysis resulted in identification of three salient themes: 1) Success elements; 2) Facilitators; and 3) Future Enablers. These salient themes capture facilitators and barriers to the program’s implementation and ability to become part of routine practice. Conclusions: The C-CriSTAL initiative in SWS was well accepted and perceived as valuable and beneficial for patient’s health care. The tool enhanced clinician’s confidence in initiating earlier EOL discussions and empowered patients to express EOL wishes in a comfortable environment then subsequently documented in the form of an advance care directive (ACD). However, challenges to sustain the program as a whole in the longer term were evident due to issues of time, funding, education/training for staff. Relevance to Clinical Practice: This study provides insight into the practical considerations as well as barriers and facilitators to the implementation of C-CriSTAL package in primary healthcare setting.
Highlights
The tool enhanced clinician’s confidence in initiating earlier EOL discussions and empowered patients to express EOL wishes in a comfortable environment subsequently documented in the form of an advance care directive (ACD)
By understanding the experience of healthcare practitioners and researchers who participated in the design and implementation of the project, this study aims to identify practical considerations associated with the development and implementation of Advance Care Planning Implementation Package (ACPIP) in South Western Sydney (SWS), Australia
The findings present potential resolutions to challenges found in sustaining the program which could be achieved via provision of more resources and funding for Advance Care Planning (ACP), remuneration for time spent in training staff and building a model that incorporates these consultations as a part of routine practice including specific billing
Summary
The literature shows substantial increase in the number of older people with frailty and chronic conditions which represent the largest proportion of patients in the hospital and Emergency Departments (ED), posing increased practical, financial and ethical challenges for the health system (Silverman et al, 2004; Schofield & Earnest, 2006; Lamba et al, 2012).Reports from the NSW Ministry of Health have indicated a systematic failure of the existing system in identifying people with end-of-life (EOL) care needs and offering appropriate treatment plans (Lamba et al, 2012; Clinical Excellence Commission, 2018). Previous systematic reviews have confirmed that General Practitioners (GPs) working closely with specialist services such as palliative and geriatric care need to develop strategies to support a more sustainable model of working at the community level (Davison & Shelby-James, 2012). The validation and implementation of the tool were supported by the National Health Medical Research Council program grant and validated across several hospital settings (Cardona-Morrell & Hillman, 2015; Cardona-Morrell et al, 2017). This tool has mainly been validated and implemented in ED
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