Seamless Care Kota Kinabalu Model_srmornachua

Morna Chua

In Kota Kinabalu, Palliative care is provided by the Palliative Care Unit of Queen Elizabeth Hospital and the Home Care Program of the Palliative Care Association.

Associated with more indicated preventive care, better identification of patients’ psychosocial problems, fewer emergency hospitalizations, fewer hospitalizations in general, shorter lengths of stay, better compliance with appointments and taking of medications, and more timely care for problems.

Seamless care is a client-oriented system composed of both services and integrating mechanisms that guides and tracks patients over time through a comprehensive array of health, mental health, and social services spanning all levels of intensity of care.

Aim : To bring the hospital to the home of the patient

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An Inpatient Service

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Clinic

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Home care program

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Daycare Service B

t F ll

INPATIENT SERVICE

- 4 beds „ 1996 - 10 beds „ 2001 - 12 beds

The active total care of patients whose

„ 1995

Presently still catering for patients with advanced incurable cancer

The goal of palliative care is the achievement of the best quality of life for the patients and their families .

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disease is not responsive to curative treatment . Control of pain & other symptoms of psychological, social and spiritual problems is paramount .

To provide a place of rest and to improve the quality of life for advanced cancer patients

1.

Provide good pain & symptom control

3. To provide respite for the primary carer and the family

2. Providing information and explore concerns/issues

4. Empowering primary carer

Patient area Kaunter

Entrance to Palliative Care Unit

Lounge

Single room Double bedded room

Prayer room Pain control „ Symptom control „ Radiotherapy „ Chemotherapy „ Respite „ Psychological support „ Final hours „

Caring in our service is holistic PCU facilitate direct admission 24 hour service respect

touch of love

for

Religious beliefs Specialized and individualized care

2 sessions held weekly New referrals „ Follow up „ Topping up of medications „

Non governmental charitable organisation providing free service

HOMECARE PROGRAM

„ Covers

a radius of 30km of PCA building

„ Must

carer

have a primary

Home Visit

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Provides medical aids on free loan basis

Some of the areas visited by our home care team Patients registered with PCU may gain direct admission to the ward when needed. But, the ward need to be informed. (all patients registered with PCU will have phone contact of the unit) „ „

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A referral form with detailed information will be filled up and sent to PCA .

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Always try to introduce home care nurse to patient before patient is discharged

Patients from the districts are referred back to their respective district hospitals Referral back to the hospital with the treatment ordered for symptom control and to contact PCU when the need arises.

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Report of incoming calls and patients under the home care program will be informed to the PCA team every working morning.

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PCA team reports back to PCU everyday after their home visits. (Fax machine provided by PCA)

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Home care team can liaise directly with PCU staff on any problems encountered by patients at home. PCU staff can contact the Home care team when patient or family members call up in case of any problems

Patients stay in hospital is short as they are discharged after symptoms are controlled. They are given the reassurance that the home care team will be following up them and they may be admitted directly to the inpatient unit when needed.

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Care is provided for not just the patient but the family as a whole; psychological issues can be the cause of difficult pain control.

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Medications of patients

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If patient is not ambulant or not able to come for review, medications can be replenished based on the assessment by the home care team.

Weekly case review

This is only possible because of the partnership of the inpatient unit and the home care team working hand in hand.

☺ Easy/direct access to Palliative Care Unit & the Home Care Team

☺ Hospital stay can be reduced thus the cost too.

☺ Logistic problem – with the help of the home care program, patient can now be adequately cared for at home especially when their condition deteriorates.

☺ Family members are able to cope better when they are taught how to take care of their loved one and reinforced by the home care team.

Symptom controlled in PCU Follow-up by home care

Patient can still be cared for at his own environment and be with his/her loved ones.

DAYCARE CENTRE

Difficulties Encountered „

Communication

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Policy of hospital

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Increase workload

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Expectations

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Problem in sustaining trained staff

Patients are cared for by Palliative Care team till they ‘rest in peace’ With good teamwork, everything is made possible.

BEREAVEMENT FOLLOW-UP

Teambuilding