Integrating specialist palliative care into residential care for older people: a stepped wedge trial (INSPIRED trial)

Indirect support 1. Needs rounds. Needs rounds are monthly 60minute triage (and risk stratification) meetings, where up to ten residents with a short prognosis and high symptom burden are presented by facility staff to the specialist palliative care clinician. Residents do not attend needs rounds. Discussions focus on treatment/symptom management planned. Case-based education is integrated into the needs round, with each resident’s bio-psycho-social status discussed to promote symptom management, and identify opportunities to extend and reinforce staff knowledge. The markers for a prognosis of six month or less, taken from the Palliative Approach toolkit (Parker & Hughes 2010), are used to identify residents to be discussed in needs rounds: a. Answering “no” to the question would you be surprised if the resident died within the next six months b. Significant functional or medical decline c. Conflict concerning whether goals of care should be curative or palliative in intent (e.g. after an acute event) d. If the resident is transferred or admitted to the facility specifically for comfort or palliative care Needs rounds frequently lead to initiating the other elements of the model. 2. Case-based education for staff. There are multiple opportunities for educating staff within the model that the specialist palliative care team engage in. Specifically, education may focus on communicating with residents, relatives and GPs, symptom management approaches, identifying deteriorating patients. Education will be provided at the monthly needs rounds to attending staff. This may include some didactic teaching as well as socratic method. All education will be based on the clinical cases presented during the Needs Rounds. Needs rounds last one hour, the education component may be around half of this time. 3. Case conferences. These meetings between facility staff, resident, relatives and relevant health care providers (including, but not limited to the GP, geriatrician, dementia services) and are facilitated by either the GP or facility staff. Case conferences are attended and facilitated by specialist palliative care staff at the beginning of the intervention to model how to conduct the meetings. As the facility staff gain confidence, they take over the chair function, and specialist palliative care are involved only when resident/family have complex physical, psychological or social needs. The agenda focuses on resident and/or family concerns, moving to discussion of how quality of life could be improved, goals of care (including discussion about hospitalization), and completion of an advance care plan. Medications and care plan may be changed as a consequence of these discussions. The facility staff explain their capacity to achieve the goals which have been described. Case conferences will be organised on an 'as required' basis, as identified in the needs rounds.. Typically, they last one hour. Often only one case conference will be required per resident. Direct support 4. Clinical work with relevant residents. Both needs rounds and case-conferences may lead to referrals for direct specialist palliative care clinical work with residents. Clinical referrals may also arise from other residents who have not been discussed in needs rounds or case conferences. Direct clinical work involves: symptom assessment, diagnosis, symptom management. At times, direct clinical work with residents also included Chairing case-conferences. However, as the model proposes that these are primarily driven and led by the facilities, they are primarily conceptualised as indirect care. Only the most complex case-conferences are Chaired by the specialist palliative care team, for example where staff report that family conflict over goals of care requires specialist intervention to explain how symptoms and end of life can be supported. Duration of intervention will vary. Since this is a stepped wedge design, some facilities will receive the intervention for 13 months, and the last facilities to join the study will receive it for four months.