Who in the Practice Could Benefit
Many patients in general practice will be older. Many will have a number of different conditions.
The most important identifier might be a simple question:
‘Would you be surprised if the patient dies within the next six months?'
If it is likely that this patient could die, a palliative care case conference may be a mechanism for organising care and clarifying whether continuing care at home and a home death is possible.
Other triggers that can prompt thinking about the patient’s changing status could be:
- The patient is no longer able to attend the practice without significant assistance.
- There are changes in their pattern of attendance at the practice.
- There is a sudden decline or deterioration in their health.
- They have been in hospital.
- The family has indicated concerns about their health.
- The older person is actually indicating that they are unwell and don’t want more treatment.
General Practice nurses can check a number of things as part of their role.
Many of these could be undertaken as part of their normal involvement with patients.
Some of these activities could help confirm if a palliative care case conference would be valuable while others would be practical steps to support a successful case conference.
Nurses can:
- Let the GP know that things are changing for the patient and suggest a more structured review and approach to care would be useful.
- Check whether a palliative care service is already involved in the care of their patient.
- Talk to the patient to see if they are concerned that their health is getting worse.
- Check if the patient is thinking about other care arrangements (e.g. moving in with the family, moving to an aged care facility, meeting with their case manager scheduled).
- Find out if the patient has family supporting them.
- Check if the patient has completed advance care planning and has documents they could share.
- Confirm what services the patient already has in place at home (e.g. home care package, nurse visits etc) and how well they are working.
- Schedule a long patient appointment with the GP to discuss changes in the patient’s health and the need for planning for future changes.
- Suggest that a family carer may want to attend a consultation, with the patient’s permission, to discuss changes in their condition and to introduce the possibility of a palliative care case conference.
- Provide the patient and their family with information on what a case conference is.
If a case conference is seen as appropriate and a palliative care service is involved, the General Practice Nurse could liaise with the service to determine how the arrangements should be made.
If a case conference is seen as appropriate and a home care package is in place, the General Practice Nurse could liaise with the provider to determine how the arrangements should be made.
If a palliative care case conference is scheduled, the General Practice Nurse can help prepare background information for the case conference on the patient’s medical and family history.
The General Practice Nurse could also provide the family carer with information on the
Carer Needs Assessment Tool to check the impact of caring on the family member.
The General Practice Nurse as the Care Coordinator
In this model, a General Practice Nurse would be the point of contact for the patient.
They would coordinate the health care team and services involved in the care and support of the older person and their family.
The General Practice Nurse would:
- Understand and incorporate the needs and preferences of the older person and their family by working with the patient, family and care providers.
- Be aware of the lifestyle, social context, cultural and spiritual needs of their patient.
- Have contact with the relevant local health, social and volunteering services.
- Apply the principles and aims of a palliative approach in caring for the older person.
- Observe, monitor and report the older person’s and family’s needs to the GP.
Organising a MBS Case Conference
A palliative care case conference may take a few weeks to organise.
Planning is essential.
Case Conference Checklist
The GP Partners Australia
Case Conference Record and Care Plan template (183kb word doc) is an example of how to prepare, conduct and record a Multidisciplinary Case Conference.
Having one person with the overall responsibility for this ensures nothing is forgotten.
Make sure someone takes responsibility for planning and organising the conference.
- Book the case conference into the general practitioner’s patient appointment schedule.
- Find out which setting works best for the GP - should the meeting be held in their rooms, by teleconference, or in the older person's home?
- Contact all of the other participants for their availability and provide details for the meeting.
- Have an alternative plan if the meeting needs to be cancelled suddenly.
- Discuss how to distribute the outcomes from the meeting to the people involved.
- Participating in a case conference
Make sure you and the GP have the appropriate information to be able to share with the other healthcare providers to begin the process of making an individual care plan for the older palliative person that will meet their requirements for the last six months of their life.
The information you need might include:
- Clinical records.
- Medication charts.
- Advance care planning documentation.
- Family questions
- Cultural Perspectives
Specialist Palliative Care
If an older person is involved with a palliative care service, they may already have structures and processes to support palliative care case conferences. Contact the service provider to find out how they organise case conferences for patients.
If an older person is not involved with specialist palliative care, referral to a specialist service may be considered the care needs are beyond the skills of the primary health care team.
Palliative Care Case Conference Processes
More detailed information on the following aspects of palliative care case conferences is available:
Medical Benefit Scheme and Case Conferences
The Medical Benefits Scheme has a schedule of payments for GPs relating to organising and participating in case conferences.
Eligibility is based on complex care or services provided to patients with chronic or terminal medical conditions from their usual GP. At least 2 other health care providers are required for a case conference and they must also meet eligibility requirements.
There are 6 case conferencing items that are available.
MBS Items for organising and coordinating a case conference:
- Item 735: at least 15 and less than 20 minutes
- Item 739: at least 20 and less than 40 minutes
- Item 743: least 40 minutes
MBS Items for participating in a case conference:
- Item 747: at least 15 and less than 20 minutes
- Item 750: at least 20 and less than 40 minutes
- Item 758: at least 40 minutes
Further information is available
- MBS Online website for explanatory notes and item descriptors for MBS items.
- Services Australia (Medicare) for inquiries regarding eligibility, claiming, fees and rebates
Helpful Resources
Page updated 18 December 2024