Evidenced-based models of rural palliative care

An article written by Claire Marshall, PhD candidate at University of Technology, Sydney.

Almost half (45%) of the world’s population lives in rural areas, yet their access to quality palliative care is limited. [1-6] Barriers that impact access to and quality of rural palliative care include challenging terrain and a wide population distribution; challenges recruiting and educating local health care staff; limited access to specialist services and specialist clinicians (across all disciplines); and fragmented service delivery. [5]

Most people with palliative care needs want to maximise the time they spend at home and in their community. [2,3] To achieve this, patients and families need well-developed health care services [7], that includes 24-hour, 7-day-per-week access to palliative care services. [8] Rural primary care clinicians are usually well equipped to provide palliative care to patients and families with straightforward and predictable needs, while specialist palliative care clinicians/services are best placed to provide care to people with complex needs. [9] However, it is unclear which rural models of palliative care, which combine access to primary care and specialist palliative care services/clinicians, exist or work best.

We performed a systematic review to collect and synthesise the highest quality available quantitative evidence of tested rural models of palliative care to clarify which ones have demonstrated improved patient outcomes. We searched PubMed, CINAHL and Embase and identified 9508 articles. Following the review process, 15 articles [10-24] reporting on 14 studies met the criteria for inclusion. We chose the World Health Organization Innovative Care for Chronic Conditions Framework (WHO ICCC Framework) [25] as the conceptual framework, to assist with classifying the data. This framework uses 18 micro-, meso-, and macro- level elements necessary to develop models of care and health care services which address chronic conditions, including palliative care. [25] We used a narrative synthesis approach [26] and the PRISMA statement [27] to guide the reporting of results.

The included studies took place in rural areas of Australia [12,14,15,17-19,23], USA [10,11,21,24], Canada [13], Japan [16,20] and Finland [22] and involved 1831 adult and paediatric participants. The included studies used several different methods to deliver care, for example: GP-led end of life care; care coordination; complex care planning; telehealth appointments with specialist palliative care physicians; and in home respite. Most studies measured their impact by assessing changes to rates of presentation to the emergency department, place of death taking place in the site of the patients choice; changes to hospital length of stay, and changes in symptom management and quality of life scores. Using the WHO ICCC Framework [25] to identify common elements across these models, we identified the following which can optimise rural palliative care:

• A well-coordinated multidisciplinary team approach, using care planning.
• Care that is led or overseen by clinicians with specialist palliative care expertise.
• Care that is integrated across all involved health care providers, using methods to share patient information.
• Timely access to specialist palliative care clinicians and information to help patients navigate their end-of-life journey.
• Access to funding for innovative model of care design, program evaluation, and information technology infrastructure.

Using the WHO ICCC Framework [25] revealed a strong focus on micro- level elements, partial achievement of meso- level elements, and poor achievement of macro- level elements; and a lack of collaboration between study sites and macro-level departments such as governing bodies and policy makers.

Going forward, more robust research needs to take place to test model of care interventions. Rural telecommunication infrastructure needs to be improved to support access to virtual care options, and health care policy needs to be modified to align with these recommendations to enable changes to take place on a larger scale.

References

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Author

Claire Marshall

PhD candidate

University of Technology Sydney