Collaborative Supportive Care for Patients with Complex Chronic Disease

Multidisciplinary supportive care clinic management and ongoing followup as clinically required: this clinic consists of palliative care, renal medicine, general medicine, cardiac failure medicine, social work, advance care planning and complex care nurse practitioners working in a combined clinic using a multidisciplinary clinic paradigm to manage chronic disease and care plan. Face to face consultations with patients and their carers with a palliative care physician and/or general medicine physician, nurse practitioner, and social work. Medical issues will be reviewed, symptoms managed, and care planning issues reviewed, The clinic review will be on an as required basis after the initial review. These may be up to weekly if needed. All participants are reviewed until death. Patients family physicians will be provided with a summary of the consultation and a care plan to each patient. Each clinic will also have a multidisciplinary meeting to discuss each patients needs.