Delivering change in aged care for optimal palliative care and end-of-life care

A blog post written by Gabrielle Prest, Palliative Care Project Lead, Opal HealthCare National Clinical and Quality team

I am keen to share the Palliative Care (PC) Transformation project underway in one of Australia’s leading aged care providers and describe the organisational support for our journey to optimise palliative care and end-of-life care (EOLC). Opal is a private aged care provider, for over 7,000 residents, with a current footprint of 80+ care communities in 4 Australian states, and over 9,000 staff.

The need for improved PC and EOLC outcomes for residents in aged care was laid bare and has been articulated in both the national literature and in the findings of the recent Australian Royal Commission in Aged Care Quality and Safety. Poor quality end-of-life care and limited education of staff were the main findings in both settings. It was in this context that PC was included as a Clinical Excellence focus in Opal HealthCare’s Strategic Plan in 2019/2020. After coming to Opal to implement the digital health/electronic medication system, and given my background in PC, I was asked to lead Opal’s PC and EOLC work. A Framework and set of recommendations was developed in mid-late 2020 and endorsed by Opal’s Clinical Governance Committee, and the program launched in early 2021. I felt very privileged to be asked to contribute to this work and see first-hand Opal demonstrating leadership in this space nationally, with executive support to help drive change. At the time of writing this article, we are 6 months into the project.

The program of work aims to optimise PC and EOLC outcomes for our residents through three main strategy areas:

• Building the capacity of our people
• Strengthening our partnerships
• Building the evidence and demonstrating a difference through a quality improvement approach

Given the abundant evidence of what constitutes optimal PC and EOLC in aged care, being aware of limited resources to drive change across the 80 Homes in the context of competing priorities and national changes (at Opal and nationally and in the sector), a limited number of initiatives were chosen in each of the strategies above, with a realistic timeline of 12-18 months set.

In the first strategy area of education, training and professional development, we developed and have been delivering a series of face-to-face (or ‘Teams’) sessions – one hour basics or one day programs - running continuously since January 2021 and booked well into 2022. We have been targeting mostly registered nurses (RNs) but also occasionally welcoming Assistants in Nursing (AINs) as well as Lifestyle Coordinators. Over 250 nurses have been through these sessions thus far.

Since mid-2020 we have been working with the team at palliAGED to help shape and test their 10 x 15 minute palliAGED Introduction modules, launched in National Palliative Care Week in late May 2021. We assigned these modules in our mandatory learning online platform to all registered nurses. In the 2 months to late July, over 33,000 modules have been completed by our team members. We have been really impressed by the uptake and enthusiasm! Whilst we know palliAGED may be working on simplifying the modules for AINs into the future, we took the decision to also assign a number of the RN versions to our AINs as mandatory education in our learning system. The modules are well supported by the Practice Tip Sheets and we will work to continue to encourage the RNs, Champions, and Clinical Nurse Educators to embed the Sheets as part of their local educational activities.

The remaining part of this strategy area is implementing the Champion model (like the Clinical Leads or Link models) – which has worked successfully in the acute sector. Depending on the size of the Homes, a minimum of one but up to 4 Champions have been recommended for each home to help drive activities and embed those as ‘business as usual’, as well as championing the message that the provision of PC an EOLC are the basics or the core of aged care work. This model also aims to take the pressure off the Care Manager of the Home and allows a professional development path for those keen to grow their knowledge and skills in PC. Certainly encouraging these nurses to think about postgraduate education is a goal of mine too – but first things first!

Reaching all the Champions when they don’t always access emails, across 80 sites, is a challenge! We also engage the Care Managers, General Managers, the Clinical Nurse Educators, as well as ensure the ‘buy-in’ of the Regional Management Teams, using those direct reporting and communication lines. So a communications plan has always been an important component of this project – like any project – with frequent, consistent messages for the relevant audiences!!  Home TV screens with national corporate messages have also been used.

In the Strengthening our Partnerships strategy, we have been focusing on messages around utilising specialist PC Services in the more complex or challenging PC/EOLC situations, rather than reliance on them. We have encouraged our home leaders to reach out to start having conversations about our improvement work as well as discussing what work can be done together. We are going to work towards the development of agreements at the local level as to what is possible. We know that specialist PC Services come in different shapes and sizes and that funding mechanisms at the state or national level through different entities (local health services, Primary Health Networks, etc.) mean that we can’t have a one size fits all approach. But it is here that we need to see what can be delivered as in-reach support – be that only telephone consultation or full PC needs rounding based on PC needs screening (via the SPICT-4ALL tool), the provision of specific and opportunistic education, etc. Some of this will take coaching and mentoring of Home leadership teams to deliver this relationship or partnership approach, but we have anticipated that to help drive these improvements as part of the project.

And in the final strategy arm, taking a Quality Improvement Approach, is where we aim to build the evidence around improvements and embed business as usual practices. The range of initiatives in this strategy include:

• the introduction of SPICT-4ALL PC needs screening tool and monitoring of that;
• the introduction of the ELDAC After Death Audit – with baseline (time point 1 June) and then continuing and regular audit samples to evaluate practice and outcomes (it is expected that action plans at the local level will focus on any areas of improvement, as well as how this is communicated around the Home); formal reviews will be done of data at Time 1, and at 6 monthly intervals;
• working with the existing software vendor to embed these tools into our digital health/care systems;
• under the auspices of the Clinical Governance Committee, all policies and procedures relating to PC and EOLC are also being reviewed and updated.

Cultural change is an important part of the change management landscape of this project and the language of PC and EOLC is also being challenged – incorrect practices such as labelling residents who are clearly at an EOLC phase as ‘palliating’, or the use of Trajectory labels (A, B or C) that are funding-focused rather than person-centred are all within our target to change. The phases language of the national PCOC model are also being introduced whilst we focus on increased understanding about what is Palliative Care Stable, Palliative Care Unstable or Deteriorating, or End-of-Life Care. Consideration is also being made of what further elements of the PCOC model could be incorporated or implemented, but that may be another story for another time!

Gabrielle Prest, Palliative Care Project Lead, Opal HealthCare National Clinical and Quality team