Community palliative care service

Introducing HammondCare’s Community Palliative Care service – a compassionate and proactive team of specialist practitioners, committed to helping people to live until they die. 

The Northern Beaches Community Palliative Care Service (NBCPCS) has reshaped their working model to improve care provided to a population of over 266,000 people on the Northern Beaches of Sydney. 

This year has seen a significant change in the approach to caring for their patients, to provide a more proactive, responsive, compassionate service to those at the end of their lives. 

Strategy 

A three-pronged approach to redesigning patient management. 

1. A clinic model for mobile patients that allows for efficient input from multiple members of the team in a single visit. 
   
   
2. A robust, proactive caseload management strategy using a nurse-led model with clear expectations for patient monitoring and follow up. 
   
   
3. Palliative Care Outcomes Collaboration (PCOC) embedded morning and MDT meetings to more effectively track and manage patients who are unstable, deteriorating or terminal. 
   
   

Outcomes 

This approach has resulted in a rise in the number of patients who comfortably die at home, surrounded by their friends and family. 

Through relationship building, gaining the trust of families and carers and providing excellent specialist palliative care there has been a reduction in avoidable hospital admissions and crisis out of hours calls. 

As in-house and cross-team communication flourishes, and patient outcomes improve, morale and satisfaction within the team has lifted.  Despite working with patients and families in distressing circumstances, this happy team laughs a lot. 


This body of work was presented by Nurse Practitioner Joanne Rainback and Clinical Nurse Consultant Victoria Pieper, at the Oceanic Palliative Care Conference held in Sydney in September 2023.   

It is the hope of the NBPCS that their passion for community palliative care will inspire other community teams to replicate these strategies to optimise limited resources in their quest to provide excellent end of life care.