Approaching and reaching the end of life requires people, their families and carers to navigate increasingly complicated care systems to address their needs.
The Palliative and End of Life Care Diagnostic Report to inform this Blueprint found that current patient journeys are often poorly coordinated. This is particularly true for people with advanced chronic disease who have multiple comorbidities and a much slower and more unpredictable trajectory of functional decline (ACI, 2013). The Report also found that the needs of the patient, family and carer during their end of life journey vary over time and care setting. Services need to be responsive, coordinated and flexible in meeting these changing needs.
It has been demonstrated that navigation support and or care coordination improves clinical outcomes and the experience and satisfaction of patients, families and carers.
The ACI Fact of Death Analysis (ACI, 2015) found that in NSW, people who were in their last year of life and were hospitalised between 2011 – 2012 experienced frequent hospitalisations, being admitted on an average of 4 occasions with an average length of stay of 10 days (compared to the overall average length of stay in hospital of 4 days).
This cohort utilised approximately 1.4 million bed days at an estimated cost of over $977 million (ACI, 2015). There is evidence that community palliative care teams are effective at reducing acute care use and hospital deaths (Seow et al, 2014).
Acute care settings, particularly hospital emergency departments, cannot always provide the best outcomes or experiences for people approaching the end of life. Hospital emergency departments can be distressing, and the needs of people approaching the end of life are often incompatible with the principles of emergency medicine (Forrero et al, 2012).
We also know that nationally, 76% of residents of aged care facilities have high care needs (AIHW, 2012) and approximately 24% of residents will require a hospital transfer (AIHW, 2010).
A key action area of the NSW Government Plan to Increase Access to Palliative Care 2012 – 2016 (NSW Ministry of Health, 2012) is to drive greater integration across primary, aged, acute care and specialist palliative care services across the state.
Understanding patient journeys and designing care to improve their outcomes and experience ensures that we deliver person centred care.