Overview
This lecture introduces the Otago Community Hospice (OCH) ahead of a virtual placement visit, covering its history and current service model, its aims and access criteria, the referral and assessment pathway, the composition and role of its multidisciplinary team, the inpatient unit (IPU), and the Te Whare Tapa Whā model of hauora used to frame holistic, patient-centred care. It closes by introducing case studies to be discussed under confidentiality.
Learning objectives
- Part 1: describe the OCH facility, services and admission criteria to patients and family/whānau, accurately reflecting the multidisciplinary, holistic and patient-centred approach to care.
- Part 2: apply understanding of palliative care to an example case by identifying patient and family/whānau needs and how a palliative care service might meet those needs using a multidisciplinary, holistic approach.
Presenters
- Chris Hopkins: studied at Otago (3rd year 2003); Dunedin Hospital 2007; taught at Dunedin School of Medicine from 2008; GP training from 2011; Lecturer in Pathology at University of Melbourne 2014-16; Rural GP at Hauora Hokianga 2017-18; Hospice Medical Officer at OCH since 2019.
- Tracy-Lee Fisher: studied at Otago Polytechnic School of Nursing, graduated 1989; Registered Nurse, Dunedin Hospital from 1990; Paediatrics 1997-2021; PPF Otago University, Women’s & Children’s Health 2008-2020; Community Care Coordinator, OCH since 2021.
Otago Community Hospice: history and service model
- Started in Otago over 30 years ago, originally in an old house on George Street.
- A new purpose-built hospice with 12 patient rooms was built in 2001.
- Since then the focus has shifted from inpatient to community care because people want to stay at home.
- Half of the original patient rooms have been converted into offices for Community Care Coordinators, Counsellors, the Kaimahi Wairua (Spiritual Care Coordinator), Social Workers, the Residential Care Team, and the Outpatient clinic.
- OCH now provides a comprehensive service to over 300 patients at any time, covering the region from Oamaru to Owaka to Wanaka (sometimes Haast).
Aims, purpose and access criteria
Aim / purpose (per OCH Policies & Procedures):
- Specialist palliative care is provided to improve quality of life for patients (and families) facing life-limiting illnesses with little or no prospect of cure, where needs exceed what primary palliative care providers alone can meet.
- Care may be episodic rather than ongoing, based on specific complex needs.
- Relevant education and support are provided to primary palliative care providers in the region.
Access criteria (either applies):
- The patient has a life-limiting diagnosis with little or no prospect of cure, where needs exceed those provided for by primary palliative care providers alone.
- A relative, whānau or carer of a patient receiving OCH services requires support, advice or education that cannot be provided by primary palliative care providers alone.
Referral and assessment pathway
- Referrals can come from specialists, GPs, other clinicians, or sometimes whānau or the patient themselves.
- A hospice doctor reviews the referral to confirm it is appropriate and passes it to the community team coordinator.
- A Community Care Coordinator (CCC) contacts the patient to complete a comprehensive assessment.
- The CCC then manages the person’s palliative needs, including referring to other MDT members as indicated (e.g. doctor review or inpatient unit admission if needed).
Multidisciplinary team (MDT)
- Community Care Coordinators
- Clinical Nurse Specialists / Residential Care Team
- Social Workers
- Kaupapa Māori Care Coordinator
- Kaimahi Wairua - Spiritual Care Coordinator
- Counsellors
- Doctors
- Inpatient Unit Nurses
The patient's own GP and wider healthcare team remain closely involved: the hospice doctor advises on medications, but the GP remains the patient's main prescriber.
Inpatient unit (IPU)
- Functions as a form of intensive care unit, with the focus on “care.”
- Daytime clinical team: 2 nurses, 1 doctor, and a healthcare assistant, with ongoing support from the wider MDT.
- Capacity for up to 6 people at a time, admitted for specialist symptom management or end-of-life care.
- Most people admitted are discharged again; the IPU is not only for end-of-life care.
- Patients are often reluctant to be admitted, but tend to settle and feel at ease within about half an hour of arrival.
- Limitations: no active investigation or treatment; no long-term care.
Admission to the IPU is determined by assessment, including:
- Ensuring admission is consistent with the patient’s (and, where appropriate, family/whānau) goals of care.
- Involving the patient’s GP in the decision about appropriateness of admission where possible.
- Ensuring appropriate and adequate therapies and standard of care for the given symptom complexity have already been implemented in the community, and that admission is required because these have failed.
- The patient is clearly entering end of life, or has other symptom needs that cannot be managed in the community.
Te Whare Tapa Whā: model of hauora
OCH frames its multidisciplinary, holistic care using Te Whare Tapa Whā (Mason Durie, 1994), a wharenui (meeting house) model of hauora (wellbeing) with four dimensions, each represented by a wall/post of the house:
- Te taha hinengaro - mental and emotional wellbeing
- Te taha whānau - social wellbeing
- Te taha tinana - physical wellbeing
- Te taha wairua - spiritual wellbeing
Each dimension influences and supports the others; together they form the structure of the whare, conveying that wellbeing depends on all four being addressed as an interconnected whole.
Self-test
- State the two learning objective parts for this hospice unit.
- Describe how OCH’s service model and focus have changed since the hospice was built in 2001, and why.
- What population does OCH serve, geographically and in terms of number of patients?
- State the three aims/purposes of specialist palliative care as defined in OCH policy.
- List the two access criteria for OCH’s palliative care service.
- Describe the steps in the referral and assessment pathway once a referral reaches OCH, from receipt to ongoing management.
- List the members of the OCH multidisciplinary team.
- Explain the relationship between the hospice doctor and the patient’s own GP regarding medications.
- Describe the daytime clinical staffing and bed capacity of the inpatient unit (IPU).
- Distinguish the purpose of IPU admission from what the IPU is not for.
- List the four assessment considerations that determine admission to the IPU.
- Describe the four dimensions of hauora in the Te Whare Tapa Whā model, and explain what the whare (house) structure conveys about how they relate to each other.
Answers
Reveal answers
- Part 1: describe the OCH facility, services and admission criteria to patients and family/whānau, reflecting a multidisciplinary, holistic, patient-centred approach. Part 2: apply understanding of palliative care to a case by identifying patient/family needs and how a palliative care service could meet them using a multidisciplinary, holistic approach.
- Originally focused on inpatient care from a 12-room purpose-built hospice; the focus has shifted to community care because people want to stay at home, so half the patient rooms were converted into offices for Community Care Coordinators, Counsellors, the Kaimahi Wairua, Social Workers, the Residential Care Team and the Outpatient clinic.
- Over 300 patients receiving care at any time, across the region from Oamaru to Owaka to Wanaka (sometimes Haast).
- (1) Provide specialist palliative care to improve quality of life for patients and families facing life-limiting illness with little/no prospect of cure, where needs exceed primary palliative care alone; (2) care may be episodic rather than ongoing, based on specific complex needs; (3) provide relevant education and support to primary palliative care providers in the region.
- (1) The patient has a life-limiting diagnosis with little/no prospect of cure and needs exceeding primary palliative care providers alone; (2) a relative, whānau or carer of an OCH patient needs support, advice or education that primary palliative care providers alone cannot give.
- Referral comes from a specialist, GP, other clinician, whānau or the patient; a hospice doctor reviews it for appropriateness and passes it to the community team coordinator; a Community Care Coordinator contacts the patient and completes a comprehensive assessment; the CCC then manages the patient’s palliative needs, referring to other MDT members (e.g. doctor review, IPU admission) as needed.
- Community Care Coordinators; Clinical Nurse Specialists/Residential Care Team; Social Workers; Kaupapa Māori Care Coordinator; Kaimahi Wairua (Spiritual Care Coordinator); Counsellors; Doctors; Inpatient Unit Nurses.
- The hospice doctor advises on medications, but the patient’s own GP remains the main prescriber; the GP and wider healthcare team stay closely involved throughout.
- Daytime IPU team: 2 nurses, 1 doctor and a healthcare assistant, supported by the wider MDT; capacity for up to 6 patients at a time.
- IPU admission is for specialist symptom management or end-of-life care, and most patients are discharged again rather than dying there; it is not for active investigation/treatment or long-term care.
- Admission is consistent with patient/family goals of care; the patient’s GP is involved in the decision where possible; adequate community therapies for the symptom complexity have already been tried and failed; the patient is clearly entering end of life or has symptom needs unmanageable in the community.
- Te taha hinengaro (mental/emotional wellbeing), te taha whānau (social wellbeing), te taha tinana (physical wellbeing), te taha wairua (spiritual wellbeing). Each wall/post of the wharenui represents one dimension; the house structure shows that the four dimensions support and interconnect with each other, so wellbeing depends on all four together.