Older Australians living in residential aged care facilities (care homes) have complex clinical needs with multiple chronic illnesses, cognitive impairment, frailty, and polypharmacy. Avoidable hospital transfers, unwanted or overly burdensome treatments and not having access to specialist palliative care can all contribute to poor quality of death. Improving end-of-life care in care homes is a priority.
Palliative Care Needs Rounds (Needs Rounds) are monthly triage meetings that have been introduced in care homes to help identify and prioritise care for those most at risk of unplanned dying with inadequately controlled symptoms. Needs Rounds provide case-based education for care home staff to build confidence, palliative care knowledge, and skills. Multidisciplinary case conferences with shared decision-making include clearly documenting goals of care and prescribing anticipatory medicines, which prevents avoidable hospitalisation and increases residents dying in their preferred place.
A Needs Rounds pilot study led by Nikki Johnston in Canberra, Australia, influenced the Commonwealth Government to invest AU$32.8m over 4 years through the Commonwealth Comprehensive Palliative Care in Aged Care measure. This supports the delivery of projects that expand existing models of care or new approaches to the way care is delivered or commissioned, to improve palliative and end-of-life care coordination in care homes.
Needs Rounds have been rigorously tested through a large stepped-wedge randomised controlled trial (INSPIRED). They have been proven to;
- reduce hospitalisations providing significant cost savings to health services;
- improve quality of death and dying in preferred place of death; and
- improve the confidence, knowledge, and skills of care home staff in providing end-of-life care.
Using implementation science frameworks, we analysed interviews with staff from the care homes to examine the context, mechanisms of change, and outcomes of Needs Rounds. The results of the research and benefits of implementing Needs Rounds have been disseminated through peer-reviewed publications, conference presentations, targeted stakeholder engagement, and giving solutions-focused evidence to the Royal Commission into Aged Care Quality and Safety.
Needs Rounds are firmly embedded in 28 care homes in Canberra, led by clinicians in the Calvary Community Specialist Palliative Aged Care (PEACE) service. During the COVID-19 pandemic, the model has been successfully adapted for telehealth.
Building on the work of the INSPIRED trial, further research has implemented Needs Rounds in a rural setting, and at Calvary Healthcare Specialist Palliative Care Kogarah and Calvary Private North Adelaide. A study led by Liz Forbat in the United Kingdom has co-designed the UK model of Needs Rounds with care home staff, specialist palliative care, and NHS staff; 6 hospices in England and Scotland and around 30 care homes are involved in the trial.
One of the key challenges following successful research is ensuring uptake and implementation of the evidence into clinical practice and ensuring sustainability. Winning multiple national and local awards raised the profile of Needs Rounds, leading to regular requests for our team to support other services to help implement Needs Rounds in their local area.
Broad implementation cannot rely on individuals who already have a high clinical workload; there needed to be a mechanism to share our Needs Rounds expertise without requiring our direct involvement. The AU$10,000 HESTA Nursing and Midwifery Award for Team Excellence allowed us to develop a suite of implementation resources designed to show others how to use Needs Rounds to generate positive benefits for residents and staff.
I am so proud of our team’s work and am excited to be able to share the innovative model and the resources that we have developed. The videos and an implementation manual are free and can be accessed at www.calvarycare.org.au/needsrounds.
Juliane Samara, Nurse Practitioner, Calvary ACT Specialist Palliative Aged Care
This work will be presented at the Oceanic Palliative Care Conference 2021.