Models of Service Delivery

Overview

Palliative care is provided to meet the needs of patients living with or dying from a life limiting illness and their families. There is a need for population based planning of palliative care service provision. It has been estimated that, in high-income countries, 69%–82% of those who die need palliative care. [1] A population health approach is about focusing the planning on the population (or sub populations) rather than individuals and addressing disparities between different groups through a priorities method. [2] These groups can be categorised according to socio-demographic characteristics such as vulnerable, cultural, Indigenous, paediatric, or diseases such as dementia, HIV/AIDS and cancer. Each group will have particular needs that should be considered in the planning of the service provision to achieve the same level of access and care for all those requiring palliative care.

Such a population approach to planning will inform the development of models of service delivery for palliative care. Palliative Care Australia’s document A Guide to palliative care service development: a population based approach (551kb pdf) provides guidance on how to develop different services in response to the population needs. A model of service delivery in this context is about the framework for the delivery of care, referred to as a ‘model of care’ in the literature. A model of care broadly defines the way health services are delivered. [3] Having a clearly defined and articulated model of care will help to ensure that all health professionals are ‘viewing the same picture’; working toward a common set of goals and, most importantly, are able to evaluate performance on an agreed basis. [4] There are various models or components thereof for palliative care delivery that are found in the literature. [5] These models include care provided across the spectrum of health settings and involve the coordination of medical, nursing, allied health, bereavement and volunteer services from both generalist and specialist providers in primary care and hospitals. 

Palliative care should be provided in the setting of the patient’s choice, wherever possible. Palliative Care Australia’s document Palliative care service provision in Australia: a planning guide (633kb pdf) describes service provision that occurs across three health settings:
  • Community settings
  • Inpatient designated palliative care beds  
  • Acute hospitals.
Community settings include the patient's own home, residential aged care facilities or other locations such as supported care facilities. Inpatient designated palliative care beds can include beds in a rural community hospital, designated beds in a teaching hospital or a purpose-built hospice. Patients can be identified as needing palliative care while in an acute hospital to receive active but short term treatment for a severe injury or episode of illness, an urgent medical condition or during recovery from surgery.

Studies show that 50-90% of those asked about their preferences state a wish to die at home rather than an institution. [6] This leads to home deaths often being suggested as an outcome of high-quality palliative care. [7] However, there are several determinants on the actual place of death which include, the type of illness or underlying cause of death, structural availability of inpatient beds (Inpatient designated palliative care beds and beds in residential aged care or hospitals), gender, family structure, socio-economic or degree of urbanisation. [8] A focus on home deaths also does not take into consideration that some patients may die in their preferred location elsewhere or deaths at home where this was not the preferred option. There also needs to be the consideration that preferences for place of care may differ from those concerning place of death [9]. For these reasons, there are limitations of home deaths alone as a measure and achieving congruence between preferred and actual place of death is increasingly being used as an indicator of the effectiveness of palliative care services. [10]

As palliative care becomes a more significant aspect of Australia’s health system, the models by which palliative care is provided to individuals and to the whole community become increasingly important. The framework for Australian palliative care is outlined in the National Palliative Care Strategy 2010.

What is known

  • Models need to be dynamic to respond to the changing population demands and health system structure and drivers. They also need to be cognisant of social capital theory to understand the communities’ networks and relationships that can potentially enhance or hinder the management of end of life care. [11] Delivery of palliative care services is influenced by the nature of the health system and the country in which the palliative care services are embedded. [12] This makes it harder to establish which models of care provide the most benefits.
  • Community palliative care can reduce general health care use and increase family and patient satisfaction with care, which support families to sustain patient care at home. [13] This increases the chance of home deaths and should be provided for those who wish to die at home. [14]
  • Residential aged care facilities also provide palliative care in the community setting. The demand for palliative care in these settings is escalating in response to the increase in the older populations. This requires effective integration between different providers. Barriers and facilitators for the integration have been identified, but there is limited evidence about an effective integrated model. [15] As with all settings appropriate outcome measures are required to assess the quality of palliative care provided in residential aged care facilities. [16]
  • Palliative care in the acute hospital is usually provided by a consultative service. [17] There is evidence that using either consultative or integrative palliative care interventions in Intensive Care Units (ICU) results in the same outcomes that include the decrease of ICU and hospital length of stay (LOS). [18] Palliative care day centres are components of model of service delivery, and systematic reviews verify that attendance at these provide a positive experience.  But there is a lack of evidence on outcomes more generally. [19-20] Though some evidence shows day care services generate a renewed sense of meaning and purpose for the patient. [13]
  • Case management is a recurring feature of many successful models. [5]
There have been systematic and literature reviews that have looked at the management of care at the end of life with the role of palliative care for the particular needs for specific groups such as population and disease groups. These require consideration in the planning of the service provision.

Population groups:
  • Vulnerable groups [21]
  • Cultural groups [22-23] 
  • Intellectual disability [24]
  • Rural populations [25]
  • Paediatric [26-29]
  • Indigenous [30]
  • Prisoners [31]
  • Gay, Lesbian, Bisexual, Transgender [32]
Disease groups:
  • Dementia [33]
  • HIV/AIDS [34-35]
  • Cancer [36-37]

Active research areas

  • Costs have been measured in some settings and provided evidence that inpatient palliative care consultation programs reduce hospital costs whilst cost effectiveness in the community setting is inconclusive. There also needs to be further studies to evaluate the costs of different population and disease groups served in these settings. [14,38-39]
  • To be able to demonstrate the effectiveness of different models of care requires committed investment in skilled researchers to undertake a staged evaluation approach and the development of validated measures for the every aspect of palliative care, as some areas are less developed (eg spirituality). [40] Integrated care with cost effective and responsive systems can be evaluated by a proposed framework that takes a system approach. [41]
  • Future trials should compare the relative efficacy of different models and intensities of palliative care community services. [42] Models need to include integration between the different settings and services. More research is required to understand the costs, effectiveness and outcomes of integration, in particular for palliative care delivered in residential aged care facilities as more providers are involved. [15]
  • Models that that support alignment or integration of palliative care within other health services such as cancer care or renal care still need to be investigated. [43]

PubMed Searches

Models of Service Delivery
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Review Collection
  1. Murtagh FE, Bausewein C, Verne J, Groeneveld EI, Kaloki YE, Higginson IJ. How many people need palliative care? A study developing and comparing methods for population-based estimates. Palliat Med. 2014 Jan;28(1):49-58. Epub 2013 May 21.
  2. Australian Institute of Health and Welfare (AIHW). Population health [Internet]. 2016 [cited 2016 Feb 4].
  3. Government of Western Australia, Department of Health. Models of care [Internet]. [cited 2017 Feb 23].
  4. Davidson P, Halcomb E, Hickman L, Phillips J, Graham B. Beyond the rhetoric: what do we mean by a 'model of care'?Aust J Adv Nurs. 2006 Mar-May;23(3):47-55.
  5. Luckett T, Phillips J, Agar M, Virdun C, Green A, Davidson PM. Elements of effective palliative care models: a rapid review.BMC Health Serv Res. 2014 Mar 26;14:136. 
  6. Bell CL, Somogyi-Zalud E, Masaki KH. Factors associated with congruence between preferred and actual place of death.J Pain Symptom Manage. 2010 Mar;39(3):591-604. Epub 2010 Jan 29.
  7. De Roo ML, Miccinesi G, Onwuteaka-Philipsen BD, Van Den Noortgate N, Van den Block L, et al. Actual and preferred place of death of home-dwelling patients in four European countries: making sense of quality indicators. PLoS one. 2014 Apr 8;9(4):e93762. eCollection 2014.
  8. Thönnes M, Jakoby NR. Where people die. a critical review. Medical Sociology Online. 2013 Feb;7(1):8-19. (205kb pdf)
  9. Agar M, Currow D, Shelby-James TM, Plummer J, Sanderson C, Abernethy AP. Preference for place of care and place of death in palliative care: are these different questions? Palliat Med. 2008 Oct;;22(7):787-95. Epub 2008 Aug 28.
  10. Billingham MJ, Billingham SJ. Congruence between preferred and actual place of death according to the presence of malignant or non-malignant disease: a systematic review and meta-analysis. BMJ Support Palliative Care. 2013 Jun;3(2):144-54. Epub 2013 Jan 23.
  11. Lewis JM, DiGiacomo M, Luckett T, Davidson PM, Currow DC. A social capital framework for palliative care: supporting health and well-being for people with life-limiting illness and their carers through social relations and networks. J Pain Symptom Manage. 2013 Jan;45(1):92-103. Epub 2012 Jul 11.
  12. Hannon B, Librach SL, Zimmermann C. Palliative care program development: an international perspective. Curr Opin Support Palliat Care. 2013 Jun;7(2):192-4. (No abstract available)
  13. Candy B, Holman A, Leurent B, Davis S, Jones L. Hospice care delivered at home, in nursing homes and in dedicated hospice facilities: A systematic review of quantitative and qualitative evidence. Int J Nurs Stud. 2011 Jan;48(1):121-33. Epub 2010 Sep 16.
  14. Gomes B, Calanzani N, Curiale V, McCrone PP, Higginson IJ, Brito M. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013 Jun 6;6:CD007760.
  15. Davies SL, Goodman C, Bunn F, Victor C, Dickinson A, Iliffe S, et al. A systematic review of integrated working between care homes and health care services. BMC Health Serv Res. 2011 Nov 24;11:320.
  16. Parker D, Hodgkinson B. A comparison of palliative care outcome measures used to assess the quality of palliative care provided in long-term care facilities: a systematic review. Palliat Med. 2011 Jan;25(1):5-20. Epub 2010 Sep 3.
  17. Smith TJ, Coyne PJ, Cassel JB. Practical guidelines for developing new palliative care services: resource management. Ann Oncol. 2012 Apr;23 Suppl 3:70-5.
  18. Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ. Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med. 2014 Feb;17(2):219-35.
  19. Bradley SE, Frizelle D, Johnson M. Patients' psychosocial experiences of attending Specialist Palliative Day Care: a systematic review. Palliat Med. 2011 Apr;25(3):210-28. Epub 2011 Jan 12.
  20. Stevens E, Martin CR, White CA. The outcomes of palliative care day services: a systematic review. Palliat Med. 2011 Mar;25(2):153-69. Epub 2010 Oct 7. 
  21. Rietjens JA, Deschepper R, Pasman R, Deliens L. Medical end-of-life decisions: does its use differ in vulnerable patient groups? A systematic review and meta-analysis. Soc Sci Med. 2012 Apr;74(8):1282-7. Epub 2012 Feb 17.
  22. Bray Y, Goodyear-Smith F, Gott M. Transnationals' Experience of dying in their adopted country: a systematic review. J Palliat Med. 2015 Jan;18(1):76-81.
  23. Connolly A, Sampson EL, Purandare N. End-of-life care for people with dementia from ethnic minority groups: a systematic review. J Am Geriatr Soc. 2012 Feb;60(2):351-60.
  24. Dunkley S, Sales R. The challenges of providing palliative care for people with intellectual disabilities: a literature review. Int J Palliat Nurs. 2014 Jun;20(6):279-84.
  25. Butow PN, Phillips F, Schweder J, White K, Underhill C, Goldstein D. et al. Psychosocial well-being and supportive care needs of cancer patients living in urban and rural/regional areas: a systematic review. Support Care Cancer. 2012 Jan;20(1):1-22. Epub 2011 Sep 29.
  26. Bluebond-Langner M, Beecham E, Candy B, Langner R, Jones L. Preferred place of death for children and young people with life-limiting and life-threatening conditions: A systematic review of the literature and recommendations for future inquiry and policy. Palliat Med. 2013 Sep;27(8):705-13. Epub 2013 Apr 23.
  27. Harding R, Albertyn R, Sherr L, Gwyther L. Paediatric palliative care in sub-saharan Africa: a systematic review of the evidence for care models, interventions, and outcomes. J Pain Symptom Manage. 2014 Mar;47(3):642-51. Epub 2013 Aug 21.
  28. Montgomery K, Sawin KJ, Hendricks-Ferguson VL. Experiences of paediatric oncology patients and their parents at end of life: a systematic review. J Pediatr Oncol Nurs. 2016 Mar;33(2):85-104. Epub 2015 Jul 27.
  29. Doug M, Adi Y, Williams J, Paul M, Kelly D, Petchey R, et al. Transition to adult services for children and young people with palliative care needs: a systematic review. Arch Dis Child. 2011 Jan;96(1):78-84. Epub 2009 Nov 30.
  30. Duggleby W, Kuchera S, MacLeod R, Holyoke P, Scott T, Holtslander L, et al. Indigenous people's experiences at the end of life. Palliat Support Care. 2015 Dec;13(6);1721-33. Epub 2015 Jun 15.
  31. Maschi T, Marmo S, Han J. Palliative and end-of-life care in prisons: a content analysis of the literature. Int J Prison Health. 2014;10(3):172-97.
  32. Harding R, Epiphaniou E, Chidgey-Clark J. Needs, experiences, and preferences of sexual minorities for end-of-life care and palliative care: a systematic review. J Palliat Med. 2012 May;15(5):602-11.
  33. Goodman C, Froggatt K, Amador S, Mathie E, Mayrhofer A. End of life care interventions for people with dementia in care homes: addressing uncertainty within a framework for service delivery and evaluation. BMC Palliat Care. 2015 Sep 17;14:42.
  34. Wilkins ML, Dallas RH, Fanone KE, Lyon ME. Paediatric palliative care for youth with HIV/AIDS: systematic review of the literature. HIV AIDS (Auckl). 2013 Jul 29:5:165-79. 
  35. Simms VM, Higginson IJ, Harding R. What palliative care-related problems do patients experience at HIV diagnosis? A systematic review of the evidence. J Pain Symptom Manage. 2011 Nov;42(5):734-53. Epub 2011 May 26.
  36. DiMartino LD, Weiner BJ, Mayer DK, Jackson GL, Biddle AK. Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review. J Palliat Med. 2014 Dec;17(12):1384-99. 
  37. Hui D, Kim YJ, Park JC, Zhang Y, Strasser F, Cherny N, et al. Integration of oncology and palliative care: a systematic review.Oncologist. 2015 Jan;20(1):77-83. Epub 2014 Dec 5.
  38. May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014 Sep;17(9):1054-63. Epub 2014 Jul 1.
  39. Langton JM, Blanch B, Drew AK, Haas M, Ingham JM, Pearson SA. Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: A systematic review. Palliat Med. 2014 Dec;28(10):1167-96. Epub 2014 May 27.
  40. Evans CJ, Harding R, Higginson IJ; MORECare. 'Best practice' in developing and evaluating palliative and end-of-life care services: a meta-synthesis of research methods for the MORECare project. Palliat Med. 2013 Dec;27(10):885-98. Epub 2013 Jan 15.
  41. Bainbridge D, Brazil K, Krueger P, Ploeg J, Taniguchi A. A proposed systems approach to the evaluation of integrated palliative care. BMC Palliat Care. 2010 May 10;9:8.
  42. Luckett T, Davidson PM, Lam L, Phillips J, Currow DC, Agar M. Do community specialist palliative care services that provide home nursing increase rates of home death for people with life-limiting illnesses? A systematic review and meta-analysis of comparative studies. J Pain Symptom Manage. 2013 Feb;45(2):279-97. Epub 2012 Aug 20.
  43. Bruera E, Hui D. Conceptual models for integrating palliative care at cancer centers. J Palliat Med. 2012 Nov;15(11):1261-9. Epub 2012 Aug 27.
Last updated 23 February 2017