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Title Shared Renal-Palliative Care Model For Conservatively Managed End Stage Renal Disease Patients |
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Type Poster Presentation |
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Theme 18th Asian Colloquium in Nephrology (18th ACN 2019) |
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Topic Chronic Kidney Disease: Palliative and End-of-life Care |
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Main Author Amy Lim1 |
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Presenting Author Amy Lim1 |
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Co-Author Alethea Yee3 Clinton Shi2 |
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Department / Institution / Country Speciality Nursing / Singapore General Hospital / Singapore1 Medical Social Services / Singapore General Hospital / Singapore2 Department of Palliative Medicine / National Cancer Centre Singapore / Singapore3 |
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Abstract Content: Introduction, Method, Result, Conclusion Background and Methodology As Singapore faces an ageing tsunami, palliative care becomes increasingly important. While most Singaporeans prefer to pass away at home, only 27% of deaths happened at home, with majority in hospitals. Ministry of Health (MOH) aims to increase the percentage of home deaths by promoting home hospice services and advanced care planning. For end-stage renal disease (ESRD) patients who opt for conservative management, palliative care becomes an important alternative to RRT and as they become frailer, community services take on an increasing important role to support them. But referrals to home hospice for such patients remain patchy while visits to hospital visits continue despite increasing difficulty by patients to do so as they deteriorate. Yet there is evidence that a good home hospice program can reduce hospital admissions and increase home deaths. We interviewed 27 conservatively managed ESRD patients (“ESTHERS”) that attends the Low Creatinine Clearance Clinic (LCC) at SGH from May 2017 to address their concerns and needs. We aim to reduce hospital clinic visits and admissions, as well as increase home hospice referrals and home deaths. Proposed Solution : New Model of Care From Jan 2018, a multidisciplinary healthcare team discuss all ESTHER cases before each clinic and agree on their care plans, medication reviews, and future case management. A referral criteria to home hospice was agreed. Assisi home care was chosen to ensure consistent standard of care. We started monthly teleconference with Assisi on ESTHERs known to both teams. Queries arising patient care in between teleconference are quickly resolved through secured group chats. The main point of contact between the teams are the HomeCare Nurses and the Renal NurseClinician. Future Plans To track hospital admissions and clinic visits, place of death of ESTHERS and compare with historical cohort before shared care model was implemented. |