a end-of-life programmetsaofoundation.org/doc/ihcno/breakout_session/pcn_1.pdf · (jan 2012) a)...

A EVALUATION OF

A END-OF-LIFE PROGRAMME

EMBEDDED WITHIN A COMMUNITY

LONG TERM CARE MODEL

IN SINGAPORE

© 2014. Tsao Foundation, Not to be reproduced or disseminated without permission.

© Tsao Foundation. No unauthorised reproduction.

• HMMC Model of Care

• Components of EoL Programme

• Evaluation of the EoL Programme

• Primary Care Model in Action

LINEUP FOR THIS SHARING…



Frail and Nursing Home Eligible Elders

Elders with Difficulties

in……

HMMC’s Target Population

Financial Difficulties

Psychological

Factors

Environment

Limitations

Physical

Needs / Abilities Social

Determinants

CNY Outing

in 2013



ASSIMILATING END OF LIFE CARE INTO

HUA MEI MOBILE CLINIC SINCE OCT 2009

Since its inception in1993, HMMC has been delivering

Team-Managed Primary Health Care

to homebound and frail older persons

at their home.

Components since 2009

- End of Life Care Training

- Person-Centred Care

-Increased Resourcing

-- 24 E-line



MY TEAM MEMBERS

Doctors, Nurses, Social Worker

& Programme Coordinator


© Tsao Foundation, 2013. No unauthorised reproduction.

MEDICAL PROFILES OF OUR CLIENTS



Time

Functi

on

death

High

Low

Dementia/Frailty Trajectory

HMMC’s Clients’ Common Trajectories

Time

Functi

on

death

High

Low

Organ System Failure Trajectory

A steady decline, with peaks and valleys,

which may take weeks to months to even

years to progress towards death.

As death approaches, the decline becomes

rapid.

Generalized frailty of all body systems or

neurological failure (such as Alzheimer's and

other dementia) resulting in a dwindling

trajectory towards death.

Our Clientele Range



OUR ECHO

‘Primary care professionals

have the potential &ability to provide

end of life care for most patients,

given adequate training, resources,

and when needed, specialist advice.

They share Common Values with palliative care specialists –

Holistic, Patient Centred Care,

delivered in the context of famillies and friends.’



COMMUNITY NURSE & COMMUITY PALLIATIVE NURSE

• Provider

• Advocate

• Care Manager

• Monitor

• Educate

• Provider

• Advocate

• Care Manager

• Monitor

• Educate

• Innovate

• Facilitate

Community Nurse Community Palliative Nurse

Palliative Care Training

Its Really More SAME than Different !



INTERVENTIONS (EOL PATIENTS)

• Client’s

Needs

• Caregiver’s

Needs

• Domain of

Care

• Care Plan

• Care Mx

• Advocacy

• Identify

Caregiver

Stress

• Caregiver

Training

• Discussion

of ACP

• Proper

Documen-

tation

• Revisit at

each

Crisis

• Mortality

Round

• Follow Up

• Evening of

Remembr

-ance

Assessment Continual

Communication

Advance

Care

Planning

Caregiver

Support

Bereavement

Support

An Evaluation of

HMMC EoL CARE PROGRAMME

(1 Oct 10 – 30 Sep 12)



ADVANCE CARE PLANNING

ACP Without ACP

98% (54)

2% (1)

ACP discussed



Preferred Place of Death

46 (84%)

2

6

10

5

10

15

20

25

30

35

40

45

50

Home Hospital No Preference Not known



24

32 2

1 1 1 1 1

0

5

10

15

20

25

30

CAUSE OF DEATH N=36



28 (78%)

8 (22%)

Home

Hospital

N=36

Number of Deceased who died in a Place against their Wishes = 5

3 were due to care givers’ choice

2 lived alone

Places Where Death Took Place



“DO YOU FEEL YOUR LOVED ONE HAD A GOOD DEATH?”

FEEDBACK BY TELEPHONE



Mdm Tan

A CASE DEMONSTRATION

I might not

remember my

age anymore

I am a

homemaker

and love to

stay home

I might be noisy

at home and

may not sound

right

I trust that my

daughters will

take care of my

needs.

But I am sure I

want to spend

all my days at

home

Mdm Tan I love and

care for my

children very

much.



SUPPORTIVE PARTNERS SYSTEM

Caregivers (2 daughters)

Nurse

Social Worker

Doctor

Community Resources

Family Members

Mdm Tan



HMMC’s JOURNEY with MDM TAN

Admission

(8/9/2009)

Goal of Care:

Maintenance

First Crisis

(15/11/2011)

a) Pneumonia

b) Critically ill

c) EoL Prog

Transition

(Jan 2012)

a) Stable

b) Improved

QoL

c) Maintenance

Second Crisis

(30/4/2013)

a)Pneumonia

b)General

Decline

c)Re-Transit

back to EoL

Programme

Passes On

(22/8/2013)

a)In the comfort of own home

b)Among family members

c)As per her ACP



PRIMARY CARE MODEL – THE 9 ‘C’S

Mdm Tan

First Contact

Continuity

Caregivers

Care Mx

Comprehensive

Care

Communication

Community

Counselling

Coordination



• Most older persons experience a ‘Dwindling’ Death Trajectory

• A Primary Care Team - LTC empowered and enabled to provide

EoL Care may reduce the need for hospitalization

• Minimize the Person’s Need to Switch between care settings

and primary care providers

• Therapeutic Rapport between patient / family / care teams can

be harnessed to improve quality of care

REFLECTIONS

“YOU matter because You are You, and You Matter to the End of Your Life.

We will do All we can not only to help you die peacefully,

but also to

Live Until You Die.”

- Dr Dame Cicely Saunders

THANK YOU

Acknowledgements:

•To my team at Hua Mei Mobile Clinic past and present

•To all who has helped in the data mining and collation

•Especially to all Elders & Family, current and before, whose wisdom

are my constant teachers

•To all of you, my fellow companions on this journey.

a end-of-life programmetsaofoundation.org/doc/ihcno/breakout_session/pcn_1.pdf · (jan 2012) a)...

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