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Models of Care

Key Messages

  • Not all people at the end of their life will need specialist palliative care but a palliative approach or palliative care should be available when and where it is required. [1]
  • A model of care broadly defines the way health services are organised and delivered. [2,3] The chosen of model of care can affect the quality of the care. [4]
  • Various models for palliative care delivery and their components exist [2-7] without there being a universally accepted model. [8] However, models of palliative care appear to show benefits for patients and their carers, with no evidence of negative effects, irrespective of setting or patient characteristics. [3]
  • Effective models are becoming increasingly important as the population ages and as the number of people living with multiple chronic conditions increases. [2,3,6,7]
  • For older people, community palliative care and palliative care in residential aged care facilities (RACF) have shown to be beneficial but more high-quality research is needed for the benefits and cost-effectiveness to be well understood. [9,10]

Background

A model of care broadly defines the way health services are organised and delivered. [2,3] It outlines best-practice care and services through core components (the components describe who delivers which intervention, when, where, how, to whom, and for what purpose) and principles that sit within a framework that provides the structure for the implementation and subsequent evaluation of care. [3,4]

End of life refers to the period during which people live with advanced illness that will not stabilise and from which they will die. It may or may not be limited to the period immediately before death. [6] Multiple services are required to support these people and their families. The model of care used to deliver these services can affect the quality of the end-of-life care. [4] 

Evidence Summary

The framework for Australian palliative care is outlined in the Palliative Care Service Development Guidelines. [1] Palliative care is provided to meet the needs of people living with or dying from a life-limiting illness and to support their families. Not all people at end-of-life will need specialist palliative care but appropriate care when and where it is required care should be available. [1] A palliative approach and general palliative care can be delivered in many settings and by a variety of professionals, including specialists as well as generalists (GPs, nurses, nurse practitioners, allied health professionals, and carers, and volunteers. [1,3,6,11,12] Specialist palliative care can be delivered in settings such as general hospital wards, dedicated palliative care hospital wards, hospices and in the community. [11,12]  Palliative care teams generally include at least one professional with advanced training in palliative medicine. [11]

To date, a universally agreed model of care for palliative care does not exist as such. [8] A European consortium has proposed a framework for integrated palliative care which pulls together existing validated components of care. The important components of this framework are a multidisciplinary team trained in palliative care with a threefold focus: on treatment (of physical and psychological symptoms), consultation (discussions of care planning and care goals) and ongoing training. [8]

Various models for palliative care delivery and their components are found in the literature. [2-7] These models are becoming increasingly important as the population ages and as the number of people living with multiple chronic conditions increases. [2,3,6,7] Models need to be dynamic to respond to the changing population demands (including the needs of vulnerable populations), the health system structure and the policy, sociocultural and economic context. [3,10,11] The degree of integration among settings, specialties, and services is a key system feature that influences both the quality of care delivered and the outcomes. [6]

Certain models focus on a specific condition (e.g. dementia, COPD, heart failure) or care setting (e.g. residential aged care). [6] Some describe the provision of care by specialist teams in palliative care for people with complex problems and/or generalists in palliative care (including primary and geriatric care) treating those with progressive conditions. [6] Most models include a comprehensive assessment, with an emphasis on supporting functional and mental capabilities and enabling the pursuit of those things important to the person. [6]

Models for residential aged care (RAC) propose delivery of palliative care by external specialists and/or on-site staff with varying degrees of building capacity for aged care staff to care for older people throughout their period of decline or who are dying. [6,7] Training and upskilling are key components of all models; particularly training in the management of pain, dyspnoea, fatigue, anxiety, delirium, nausea/vomiting, irregular bowel functioning, oral care and depression and for the recognition of deterioration and of residents who are actively dying. [5-7] Experiential learning experiences such as careworkers shadowing hospice workers have helped careworkers to be more comfortable talking about death and dying with other staff, residents and family members. [7]

Palliative champion teams can build capacity and facilitate the sustainability of a palliative care program particularly if the champion team aligns itself with the philosophy and structure of the RACF. [5,7] Champions often focus on clinical care, education, and advocacy, but building relationships internally and with relevant community (external) partners are also important. [7] Champions can be part of creating a culture of ongoing development for staff so that they feel supported and confident in the delivery of care and suggestions of improvement to practice. [5] Management has a key role to play in supporting the implementation of change and its sustainability. [5] If new practices are embedded into day-to-day care and training programs, the improvements are less likely to be affected by the changes in staff. [5]

Evidence has shown improvements to the quality of life of people supported by the Integrated Geriatric Care and Integrated Palliative Care models of care with improvements in function and the reduction of symptoms such as pain. [6]

Community palliative care can reduce general health care use and increase family and patient satisfaction with care, which support families to sustain patient care at home. [3] There are indications that it increases the chance of home deaths and should be provided for those who wish to die at home but this research is not specific to the care of older people. [3,9,10]

Care via a palliative care day centre is a component of a model of service delivery, and systematic reviews demonstrate that attendance at these provide a positive experience, yet evidence is lacking in terms of clinical effectiveness and effect on wellbeing. [13,14]

Quality Statement

The evidence relating to models of palliative care in the community and residential aged care is emerging. [5-7] The quality of the evidence is generally acceptable to high.
 


Page last updated 30 June 2021

  • References

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  1. Palliative Care Australia (PCA). Palliative care service development guidelines (340kb pdf). Canberra: PCA; 2018.
  2. Luckett T, Phillips J, Agar M, Virdun C, Green A, Davidson PM. Elements of effective palliative care models: a rapid review. BMC Health Serv Res. 2014 Mar 26;14:136.
  3. Brereton L, Clark J, Ingleton C, Gardiner C, Preston L, Ryan T, et al. What do we know about different models of providing palliative care? Findings from a systematic review of reviews. Palliat Med. 2017:269216317701890.
  4. Health Quality Ontario. Team-Based Models for End-of-Life Care: An Evidence-Based Analysis. Ont Health Technol Assess Ser. 2014 Dec 1;14(20):1-49.
  5. Froggatt KA, Moore DC, Van den Block L, Ling J, Payne SA; PACE consortium collaborative authors on behalf of the European Association for Palliative Care. Palliative Care Implementation in Long-Term Care Facilities: European Association for Palliative Care White Paper. J Am Med Dir Assoc. 2020 Aug;21(8):1051-1057. doi: 10.1016/j.jamda.2020.01.009. Epub 2020 Feb 28.
  6. Evans CJ, Ison L, Ellis-Smith C, Nicholson C, Costa A, Oluyase AO, et al. Service Delivery Models to Maximize Quality of Life for Older People at the End of Life: A Rapid Review. Milbank Q. 2019 Mar;97(1):113-175. doi: 10.1111/1468-0009.12373.
  7. Kaasalainen S, Sussman T, McCleary L, Thompson G, Hunter PV, Wickson-Griffiths A, et al. Palliative Care Models in Long-Term Care: A Scoping Review. Nurs Leadersh (Tor Ont). 2019 Sep;32(3):8-26. doi: 10.12927/cjnl.2019.25975.
  8. Siouta N, Van Beek K, van der Eerden ME, Preston N, Hasselaar JG, Hughes S, et al. Integrated palliative care in Europe: a qualitative systematic literature review of empirically-tested models in cancer and chronic disease. BMC Palliat Care. 2016 Jul 8;15:56.
  9. Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013 Jun 6;(6):CD007760. doi: 10.1002/14651858.CD007760.pub2.
  10. Luckett T, Davidson PM, Lam L, Phillips J, Currow DC, Agar M. Do community specialist palliative care services that provide home nursing increase rates of home death for people with life-limiting illnesses? A systematic review and meta-analysis of comparative studies. J Pain Symptom Manage. 2013 Feb;45(2):279-97. Epub 2012 Aug 20.
  11. Kurti L, Wallace A, Thomas J, Wise P. Evaluation of the National Palliative Care Strategy 2010 Final Report. Australia: Urbis for Commonwealth Department of Health; 2016.
  12. World Health Organization (WHO). Planning and implementing palliative care services: a guide for programme managers. Geneva: WHO; 2016.
  13. Bradley SE, Frizelle D, Johnson M. Patients' psychosocial experiences of attending Specialist Palliative Day Care: a systematic review. Palliat Med. 2011 Apr;25(3):210-28. doi: 10.1177/0269216310389222. Epub 2011 Jan 12.
  14. Stevens E, Martin CR, White CA. The outcomes of palliative care day services: a systematic review. Palliat Med. 2011 Mar;25(2):153-69. doi: 10.1177/0269216310381796. Epub 2010 Oct 7.

Models of Care

Definition

  1. A model of service delivery … is about the framework for the delivery of care, referred to as a ‘model of care’ in the literature. A model of care broadly defines the way health services are delivered. 
  2. A 'Model of Care' broadly defines the way health services are delivered. It outlines best practice care and services for a person, population group or patient cohort as they progress through the stages of a condition, injury or event.