Model of Care
Based on the PEACH (Palliative Extended and Care Home) model previously piloted in the South Western Sydney LHD (Girotto, Harlum & Agar 2010) the Program consists of personalised packages of care of short term (up to seven days) duration to support individuals at the end of their life. The Program involves the following core elements:
Medical governanceClinical governance remains with the client's General Practitioner.
Case ManagementCase management of the client remains with the LHD community nursing team. The LHD community nursing service is responsible for maintaining day to day care of the client in collaboration with the specialist palliative care service, ensuring that all interventions are documented in the client's medical record. Referral to the PEACH Program will not impact on the existing case management arrangements for the client.
Referral PathwayReferrals will be accepted from existing LHD services (community or hospital). Referrals may also be accepted from GPs however this will usually be made via the LHD service. A Referral form, care plan and home environment check list must be completed by the LHD service and referral coordinated in conjunction with the Silver Chain Clinical Nurse Manager (CNM).
Single entry point for PEACH referrals from all five LHDs is via the Triple I (Hub) located within SWSLHD. The centralised intake will ensure that coordination of referrals, data and feedback occurs with unmet need data also collected.
All referrals will be screened for eligibility and completeness of information by the Triple I (Hub) before transferring the referral and all supporting documentation to Silver Chain for scheduling of AIN for personal care, and evening/night nurse services.
Where a client is being referred to the Program directly from an inpatient facility an initial referral to the LHD Specialist Palliative Care Service and/or Community Nursing service must be made prior to referral to the PEACH Program. The home environmental checklist must be completed prior to referral being accepted. Process may differ for clients already known to Palliative Care Service so it is good practice to contact the nominated clinical coordinator.
Clinicians wishing to refer an inpatient onto the program must ensure that individual LHD referral pathway is followed.
Evening and Overnight Support
Evening service provided by Silver Chain include scheduled visit by specialist Palliative Care RN. Clinical Intervention based on care plan developed by LHD clinical team.
This support is gained by using the supplied electronic device - "Tablet" which has clear operational instructions provided to every client/carer). The device has been set up for one "press" ease of operation for carer/s to communicate with Silver Chain during the evening and overnight.
Clients/carers can still contact their LHD after-hours service where available.
Personal careThe Silver Chain R.N provides the first Silver Chain visit in the evening followed by the Silver Chain AIN the next day. Care provided by the AIN will be guided by a care plan developed by the evening nurse, however personal care and/or respite can be provided as required.
MedicationsMedications (or prescriptions to be filled by the family before admission to the Program) are to be arranged by the referring LHD palliative care nurse. Appropriate and current medication orders must be in place in the client's home. Silver Chain staff do not provide Syringe driver devices but are able to use LHD supplied devices.
All required equipment should be in place at time of referral. Equipment can be accessed through Equipment Loan Pool, Enable NSW, or purchased /hired privately.
At times a client may express a wish to be cared for in their own bed rather than a hospital bed. Please ensure that this is documented on the referral form. Where a hospital bed is not in place the personal care provided may need to be modified. A risk assessment may be required to ensure safety of staff involved in caring for these clients.
ConsumablesBasic consumables required during the evening visit, including dressing consumables will be supplied by the Silver Chain nurse.