Summary of the GAPS Model

The preferred model for the Program is based on that developed by the Griffith Area Palliative Care Service (GAPS), which has been evaluated by the Centre for Health Service Development, University of Wollongong.  The core components are as follows:

Governance

Governance arrangements need to ensure that three domains are addressed: 

• Care and Clinical
• Scientific Southern QLD Rural Division of General Practice
• Organisational

Firstly, governance will ensure that clients and their families are treated appropriately.  Secondly, it will ensure that the full range of project resources are employed to their best effect and that appropriate accountabilities are rendered.  Lastly, governance of this project will have the ability to answer the key policy questions about effectiveness, efficiency and generalisation for which it is being undertaken.

The Governance Committee should comprise of each of the major stakeholders and should be established with an independent chair.  The Committee will be closely involved in the detail of the project and will make decisions on policy and resource use.  Monthly reports will be received from the project coordinator or team leader. 

Importantly, the Governance Committee acts as a crucial link between an array of service providers, ensuring effective communication and common strategic goals.

A further clinical working party is recommended and should be responsible for developing the various local clinical guidelines, systems / strategies and protocols upon which the project is based.

Access line

The access line should be staffed by an integrated group that includes general practitioners, nursing staff and volunteers who are focused on the continuum of care, including bereavement.  Patient difficulties do not only occur during business hours.  A 24 hour on-call service would ensure services are responsive to consumer needs at all times. The service should offer support, advice and management including domiciliary visits, if required. The access number ensures equity and access for the consumer and their family, and should be advertised within the local area.

Interdisciplinary meeting

The composition of an interdisciplinary team will vary, depending upon the degree of the development of the project, the objectives of the project and the available resources.  Each project will be different although most will include core personnel, for example doctors, nurses and pastoral volunteers.  Inter disciplines tend to be brought in as required and maybe available on a consultation basis only.  Clearly directed staff meetings are essential for mutual support, adequate hand over and continuing communication with the other professionals who will share on-going care at one site or another. 

The situation of a patient with a terminal illness may change quickly; the regime of providing comfort today may be inadequate tomorrow.  Assessment of comfort and other therapy should be carried out often and regularly, for example as weight decreases our organ functions deteriorate; the goals and details of drug therapy may alter and decisive care may have to be reassessed.  Vying for these issues can be difficult and weekly staff meetings should provide the vehicle for planning and evaluation.  Potential problems can be discussed and appropriate measures put into place. 

Enhanced primary care items

In 1999, the Federal Government launched the enhanced primary care (EPC) package.   The goal of the EPC package was to improve the health and quality of life of older Australians, people with chronic conditions and multidisciplinary care needs through enhancing quality of primary health.  Its aim was for the minimisation of potential health risks and improvement in health outcomes, with more appropriate use of medication, home care and other services. Taking into account that clinical GP payments are MBS only the facilitation of case conferences and care plans is highly advantageous.

Case conferences provide an opportunity for the GP to organise, coordinate or participate in the conference with two or more of the health professionals or service providers.  It should identify and discuss the care goals of a patient with a chronic or terminal condition and multidisciplinary care needs.  The aim is to enable GPs to shift from short-term episodic fragmented care to a whole person care that is integrated with other health care providers. 

Care plan items are designed to include the gathering of all required information and communication with other providers.  Case conference items should not be used to gather information for care plan items.  These guidelines are laid down by the Royal Australian College of General Practitioners, ?Enhance Primary Care Standard and Guideline for the Enhanced Primary Care Medicare Schedule Items 2000?.

Uptake of EPC items is crucial to the model as it is the most appropriate way to fund General Practitioners for their input.

Note: No money will be provided to pay for increased clinical hours under the RPC program.

Improved management of patient information and data

People admitted to the project services should have an integrated patient centered medical record that generates a personal health record.  The aim of this is to ensure greater continuity of care and more efficient services.  Patients will no longer have to repeat their medical history on each presentation to each new service; more importantly to a service that has a high turnover of staff such as a Base Hospital Emergency Department.  A patient keeps their medical record with them at home and all professionals involved in the care of the patient, records information directly into the medical record.  Importantly, this information is readily accessible to the patient and ensures they are fully aware of the progress of their care.>

There are technical information requirements for the evaluation of the project as well as requirements for palliative care clinical monitoring and review. The introduction and use of a palliative care information system as a patient registration and clinical information system is therefore essential. >

Various systems are available however the implementation of such a database should have the provision for sub and non acute patient classification (SNAP) reporting as this is a requirement of various State health departments.  >

The > Programs and Projects SNAPshot palliative care information system software and its capabilities in capturing clinical data, organising client information in terms of episodes of care and discrete classes of patients, and reporting to other data and accountability systems is one obvious choice.

SNAPshot can also export to Home and Community Care (HACC MDS and CIARR), other Commonwealth Programs (DVA, Aged Care) and provides a variety of reporting formats.

An alternative is a database such as PalCIS.  PalCIS has a high level of compatibility with the Australian DoctorSNAPshot. software and is purpose-built to be clinically sensible - ie designed for rural palliative care services.Radio, print advertisements and community talks throughout all SQRDGP regions, including a major feature in Queensland Country Life

Education programs for medical officers, registered nurses, emergency department staff, pastoral care workers and volunteers

The program is placed within a broad education framework designed to enhance quality and develop common understandings between participants in a system of rural palliative care.July 2003 - SQRDGP implemented a promotional campaign throughout the Division which achieved a 2% increase in Immunisation rates (