1. Wodonga Palliative Care Service Jenny Sutter, Stacey Heer, Leanne Hills

3. First, Some Background Increasing demand on palliative care service Increasing demand for coordinated care Increasing need for patients to manage own health care

4. Our Service Health information not being exchanged Patients struggling to maintain autonomy Patient satisfaction surveys – carers want more support

5. Project Aims……. Improve Coordination of Care and Communication Improve Patient Control in Own Care and Decision Making

6. Methodology Communication Tool – patient diary Adaption versus development Mid North Palliative Care Referral and Planning Project – patient diary Challenge – adapt to suit our community based service

7. Trial Distribution Criteria Capacity Ongoing palliative care Not in a residential facility Not terminal or rapidly deteriorating

8. The Modern Health Care System Care occurs increasingly in home Treatments more complex Numerous health care providers Increased need for patients to self care

11. Provide Accurate Medical History and Medication History Modern Health Care requires patients to.....

12. Communication Barriers For Patients Poor Health Literacy Language Barriers Cognitive and Thinking issues Affects of disease and treatment

16. Communication Effects: Patients Don’t understand or follow treatment Miss appointments Take medications incorrectly Low continuity of care: low patient satisfaction More complaints

18. Communication Effects: Health Care Worker Unnecessary tests Unaware of all health care providers Double up on referrals Low continuity of care Medical errors

20. Better Continuity of Care Fewer hospitalisations Fewer emergency department presentations Lower repetition demands on patient

22. Patient Held Records…… Better Communication Patient needs more likely to be met Higher patient autonomy Less burden on health care workers End of life choices met better

23. and financial

25. Diary includes Enduring power of attorney (medical / financial) End of Life Directive Contact End of Life Wishes

26. This is special place where you can think about and perhaps write some notes on what is important to you, regarding your care at the end of life. For example: “It is important to me to stay at home for as long as possible”

27. Changes from review: Pain chart Extra plastic sleeve for reports Extra test results pages Removable calendar at back Name change to Care Diary

28. Feedback Most helpful sections: medication, appointments, glossary Everything in one place & easy to use Few took diary to specialists Approximately half took to hospital

29. Carer Feedback Improved communication between health professionals and family Felt more in control of care Comments by professionals were positive

31. Ongoing Issues for the Care Diary $ Cost $

32. No communication tool is perfect….. Keeping the diary up to date Future reviews

33. applicable for all…. The care diary is not

35. Acceptance by Health Care Providers

36. Thank you, questions, questions…….