Referral Policy
Palliative care is a basic human right to be provided by all health care providers. Specialist palliative care is required when the patient’s needs exceed the resources of the generalist providers. Anyone with a life limiting illness who requires intensive symptom control for physical, psychosocial, emotional and/or spiritual needs may be referred. By definition, the services are delivered by a multi-disciplinary team.
As a result of this broadened definition, Te Omanga Hospice Specialist Palliative Care Service now offers 2 programmes of care.
Programme I - The Comprehensive Programme
Patient Profile
These patients usually have a Trajectory I disease pathway i.e., rapidly progressive and usually results in death within a few weeks or months. The needs of these patients may exceed the resources of the generalist providers.
The programme offers all patients:
1. An initial assessment by a doctor and a nurse.
2. At least weekly home visits by one of the nurses on our homecare programme.
3. Twenty Four (24) hour nursing and medical cover.
4. Monthly outpatient appointments at the Hospice or home visits for medical review.
5. Additional services if indicated:
a) Inpatient admissions for respite and/or symptom control
b) Occupational therapy assessments at home with the lending of appropriate equipment.
c) Day centre once a week following occupational therapy assessment.
d) Additional medical home visits if required (as assessed by the homecare nurses)
e) Counselling
f) Art Therapy – especially for children
Criteria for Admission to the Comprehensive Programme
1. Uncontrolled symptoms beyond the resources of the generalist primary care provider.
2. Patient is imminently dying and has requested to die in the Hospice.
3. Early deterioration is anticipated and the patient does not want general hospital admission.
Programme II – The Partnership Programme
A shared care programme offering support to the primary care providers and clinical and ancillary services to the patients.
Patient Profile
These patients have a Trajectory II disease pathway i.e., slowly progressive and is characterized by long periods of stability punctuated by intermittent acute exacerbations. The Partnership Programme may also include trajectory I patients that are stable and asymptomatic.
The programme offers:
1. An initial assessment by a doctor and a nurse
2. Regular assessments by the Partnership Nurse who will liaise with the primary care provider
3. Attendance at day centre after occupational therapy assessment
4. Counselling
5. Art Therapy
6. Twenty four (24) hour telephone availability (a kind of helpline supplied by doctors or nurses to doctors or nurses).
NB
This programme does NOT offer:
1. Twenty four (24) nursing and medical cover to patients
2. Occupational assessment for equipment
3. Regular medical review of the patients either at home or at the Hospice
Criteria for Admission to the Partnership Programme
1. The patient may wish to return to hospital for management of the life limiting disease
2. The patient’s symptom control is optimal
3. The patient is not imminently dying and is stable
NB
1. Patients may move from one programme to the other on medical review by the Hospice doctors.
2. Patients may have interim periods on the Comprehensive Programme for intensive symptom control and once stable may return to the Partnership Programme. (ie., they may alternate between programmes)
NNB
At the initial visit, the patient, family, whanau and carers are informed of both programmes and the process for moving from one to the other. |
