1. Timely Specialist Palliative Care Service Input (Referral)
Learning Package

2. LEARNING OUTCOMES
At the conclusion of this package, participants will be able to:
understand the issues and symptoms that may benefit from SPCS input
identify when it is appropriate to consider referral to a SPCS
refer to the local SPCS including all relevant information
Have a working knowledge of the “Timely Specialist Palliative Care Input” guideline document
Feel confident to use the “LM Quick Reference Guide” for referrals
Timely SPCS Input: Learning Package

3. 1. Information you have as a Primary Care Service
Personal details
What will you have on file?
Current and previous medical condition/s
Information from GP, Medical specialist ?
Current and previous social situation
Initial assessment, carer, Social Worker ?
Current functional status
Mobility, ADLs ?
Consider one of the points opposite, then click on the question mark beside that point to see some of the things that will be beneficial.
When you have completed all of the points, click the “Next” button below.
Timely SPCS Input: Learning Package

4. Personal details - What will you have on file?
Name & address – needed to determine if the person lives in the catchment area of the SPCS
Phone number – important for the SPCS to make contact to arrange an appointment
Alternative contact – someone else to call if the SPCS can’t make contact with the person (not home, readmitted prior to appointment etc)
Does the person have a carer? Include their contact details, and identify if they don’t live with them
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Timely SPCS Input: Learning Package

5. Current and previous medical condition/s - Information from GP, Medical specialist ?
Why your service has been seeing this person
What has changed recently for this person’s medical condition
What treatments has the person undertaken during this episode of care
What treatments has the person undertaken prior to this episode of care
What medications is this person currently taking
What medications have been tried previously
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Timely SPCS Input: Learning Package

6. Current and previous social situation – Initial assessment, carer, Social Worker ?
Does this person live alone
Is the person socially isolated (distance, not able to travel etc)
What community support services are used by this person
Are there additional community supports that may benefit this person?
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Timely SPCS Input: Learning Package

7. Current functional status - Mobility, ADLs ?
Does this person use any mobility aids – wheelchair outside the house; walking frame at all times etc
Is there any additional equipment required to assist with personal ADLs – over toilet aid; shower stool; electric bed or recliner chair; lifting device etc
Does this person need assistance with personal ADLs – who is able to assist with this
Does this person need assistance with household ADLs – who is able to assist with this?
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Timely SPCS Input: Learning Package

8. The person has a terminal illness
Is this known by the person and their carer
Symptoms are not adequately controlled
Pain, nausea, dyspnoea, anxiety etc
Social or emotional issues not adequately addressed
No carer, Psychological distress
Carer is having difficulty managing
Carer strain, carer unwell too
2. What makes you consider referral to the Specialist Palliative Care Service?
Consider one of the points opposite, then click on the question mark beside that point to see some of the things that will be beneficial.
When you have completed all of the points, click the “Next” button below.
Timely SPCS Input: Learning Package

9. The person has a terminal illness – is this known by the person and their carer
Brief description of their understanding of diagnosis and prognosis – for both the person and their carer
Spiritual issues – what does the diagnosis mean for this person, has there been input by Pastoral care, Social work, Minister / Pastor (include their details to maintain continuity)
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Timely SPCS Input: Learning Package

10. Symptoms are not adequately controlled - Pain, nausea, dyspnoea, anxiety etc
Describe all uncontrolled symptoms, their current severity, and treatments previously tried – mainstream and complementary treatments
Probable cause of the symptom – may not be known, but most likely reason/s
Possible contributing factors for these symptoms – often one symptom can exacerbate another
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Timely SPCS Input: Learning Package

11. Social or emotional issues not adequately addressed - No carer, Psychological distress
There may be limited, or no family supports located close geographically
Family conflict or desire to re-establish previously broken relationships
Spiritual issues – may be cultural, religious, personal beliefs, conflict, unfinished ‘business’
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Timely SPCS Input: Learning Package

12. Carer is having difficulty managing - Carer strain, carer unwell too
Carer may be unsure how they will manage in certain situations
Role of caring has been extended in time and carer is becoming ‘tired’
Care needs are increasing, and the carer is unable to express their needs to the person they are caring for
The carer is also experiencing health and wellbeing issues that reduce their ability to provide the care they have promised
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Timely SPCS Input: Learning Package

13. 3. How to determine if referral will be appropriate
LM Quick Reference Guide and Access to Services document
Local service guidelines / criteria
Have you got your Local service information?
Needs Assessment (tools available)
What do you use now?
Consider one of the points opposite, then click on the question mark beside that point to see some of the things that will be beneficial.
When you have completed all of the points, click the “Next” button below.
Timely SPCS Input: Learning Package

14. LM Quick Reference Guide
Why use the guide? Indicates things to consider if relevant or beneficial to refer to the SPCS
Will I need to refer to the guide for every person? NO, only those who have a terminal illness you think need help
Where can I find the guide? Available from the Loddon Mallee Regional Palliative Care Consortium
See the “LM Quick Reference Guide” and the full
“Timely Specialist Palliative Care Input” guideline documents on the LMRPCC Health Workers Page
(need internet access)
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Timely SPCS Input: Learning Package

15. Local service guidelines / criteria - Have you got your Local service information?
Local service criteria for admission
Service Brochure
Contact details for the local service
General information about Palliative Care
If not sure about eligibility, talk with your local Palliative Care staff
(See what specialist services are available across Loddon Mallee region)
(need internet access)
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Timely SPCS Input: Learning Package

16. Needs Assessment (tools available) - What do you use now?
What different screening tools do you use – and for what needs? (falls risk, pressure care, depression etc)
How do you assess the ‘needs’ of a person? - Gap between current condition and desired condition
Discussion with the person and their carer – not ‘done’ in isolation
What will be beneficial for the person to improve their quality of life?
Needs Assessment Tool: Progressive Disease (NAT:PD) includes link to “Can Meet Needs” learning resource (need internet access)
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Timely SPCS Input: Learning Package

17. 4. How to make a referral Service Coordination Tool Templates (SCTT)
What are they?
Information that you have to include on the referral
What is absolutely necessary?
Specific assessments already completed
Can we use assessments done by other workers?
Avoiding duplication
How can we include more info with the referral?
Consider one of the points opposite, then click on the question mark beside that point to see some of the things that will be beneficial.
When you have completed all of the points, click the “Next” button below.
Timely SPCS Input: Learning Package

18. Service Coordination Tool Templates (SCTT) - What are they?
Statewide recommend method of information sharing
Focuses on the client to make sure they have access to the services they need
Core Templates – consumer information, summary & referral, consent, cover sheet
Supplementary Templates – Palliative Care, Functional Assessment
Optional Profiles – if information not included already
Link to download SCTT (need internet access)
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Timely SPCS Input: Learning Package

19. Information that you have to include on the referral - What is absolutely necessary?
There is a section on the Quick Reference guide to indicate what needs to be included with the referral
“Phase of Care” definitions are on p2 of the Quick Reference guide. This gives the SPCS an idea of how urgent the need is
Remember to include a contact person and the phone no of your service / agency / department
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Timely SPCS Input: Learning Package

20. Specific assessments already completed - Can we use assessments done by other workers?
Yes – include copy of relevant assessments with the referral. Make reference to the assessment in the “Description of Issues” box on Summary and Referral p1
If sending electronically, indicate if other attachments following by fax or mail
Try to think about what information you have will be useful to the service you are referring to
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Timely SPCS Input: Learning Package

21. Avoiding duplication - How can we include more info on the referral?
Read through what you have first to see where each bit will fit on the referral
Read through the referral form to see what information is being requested
Use the Palliative Care Supplement – may be beneficial to complete this first, then add other bits on Summary and Referral, or refer to the supplement instead of re- writing info.
Be specific when identifying issues and needs
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Timely SPCS Input: Learning Package

22. Congratulations!
You have now completed the “Timely SPCS Input (Referral)” training package.
You should now be better equipped to:
understand the issues and symptoms that may benefit from SPCS input
identify when it is appropriate to consider referral to a SPCS
refer to the local SPCS including all relevant information
For more information, contact your local Specialist Palliative Care Service,
or the Loddon Mallee Regional Palliative Care Consortium.
Remember to add this to your Continuing Professional Development record.
Recommended time is 1 hour of learning.