Supportive Care for Chronic Disease: An audit to evaluate the existing Supportive Care for Chronic Disease services program in the Hunter New England Health District.

An audit to evaluate the existing Supportive Care for Chronic Disease (SCCD) service program will be undertaken by clinicians or medical students or allied health students with access to Hunter New England Health District (HNELHD) medical records. The SCCD program delivers holistic and person-centred care for patients and their carers alongside existing health care (standard care). SCCD involves chronic disease care plus implementation of palliative care principles for adults living with advanced liver disease, heart failure, motor neurone disease, Parkinson’s disease, chronic obstructive pulmonary disease and Aboriginal people with advanced non-malignant comorbidities (ICCAPP), with estimated life expectancy two years or less. The SCCD service offers a 12-week program to patients and their nominated carers provided by social work, dietitian, speech pathology and occupational therapy via in-person, telehealth or virtual care. Additional psychosocial and emotional support is provided on a need’s basis by a psychiatrist for individuals assessed by the SCCD team to have elevated levels of disease related burden or distress, carer burden or psychiatric illness. Patients receive a minimum of four occasions of service and carers three occasions across the 12-week program. Patient/Carer-Reported Measures are completed electronically within 48 hours of each scheduled contact. The outcomes of these measures guide the focus of the planned consultations as well as the expressed concerns of patients and carers during consultations. Clinical care and advice are provided during consultations with additional care co-ordination and support undertaken between planned consultations according to patient and carer need. This study will be an audit of existing service data with no patient participation. Patients and carers will complete the SCCD program regardless of their involvement in this study. The audit will involve data collected from 25th August 2025 to 30 June 2032, from patient medical records (HNELHD clinical systems and databases); SCCD service data (Excel spreadsheet and progress notes populated with patient/carer demographics, scheduled appointments, attendance, referrals, interventions and planned/unplanned health service utilisations); patient/carer reported measures [Integrated Palliative Outcomes Scale (IPOS), Euroqol (EQ)-5D-5L, Malnutrition Screening Tool (MST), EAT-10 Swallowing Screening tool (EAT-10), Carer Experience Scale (CES), Carer Support Needs Assessment Tool (CSNAT) ]; and questionnaires (post service completion feedback survey). Data collection will be completed at a at a single timepoint, 6 months after completion of the SCCD program. Data will be analysed retrospectively with a focus on three timeframes, 6 months pre-referral to SCCD, during the SCCD program and 6 months after SCCD program completion. Direct identifiers will not be collected. The database will be held on HNELHD servers.