The role of PHH
Peninsula Home Hospice works with all health professionals involved in the client's care and supports them to understand palliative care.
- We recognise that all service providers contribute to high quality EOL care
- That the GP is the principal medical care provider
- That coordinated information and care that supports clients to be partners in decision making is reassuring for clients and families
We are guided by these principles:
- That dying is a part of life
- That the person is central to care
- That carers are important
- That clients have information that they can openly and genuinely discuss
- That decisions are respected
- That care is integrated from skillful staff
Often the most valuable role we can play is supporting health care teams and professionals through consultation, advice and support.
Palliative care is delivered in a variety of settings, including the home, with support from the GP, community services and often a specialist palliative care service. Palliative care is an approach to care that improves quality of life and supports the person with a life limiting illness, as well as their care network around them, often family.
Referrals to PHH can be made by clinicians, including GP’s, Specialists, hospital staff or through self referral by the family or the client. Not all people with a life limiting illness require a referral to PHH.
A referral would be appropriate according to the following criteria:
- The client has been diagnosed with a progressive and advanced illness
- Current treatment is not for curative purposes, but rather with a goal of quality of life
- Palliative issues exist, which could include the following:
- Need for assessment and treatment of symptoms such as pain, nausea, shortness of breath, anxiety or depression
- Need for Spiritual, social or psychological support to affirm life and regard dying as a normal process
- Need for a multidisciplinary team approach to assist with client and carers to manage with issues associated with living with a terminal illness, to live as actively as possible until death, and in bereavement.
The referral process
The aim of an efficient referral process is to reduce the amount of burden on the client and their family. PHH Intake Team endeavour to collect adequate information to determine the appropriateness of the referral for PHH services as well as accessing relevant information to assist with an effective holistic assessment.
It is for this purpose that our referral process is as follows:
Via online referral portal
2. Provide further medical information via fax, which includes:
- Letter of referral if specific needs or requests not identified in online referral
- Copies of relevant specialist letters (eg. Oncologist letters)
- Hospital Discharge Summary
- GP Health summary
- Copy of relevant scans and pathology results
- Relevant medication list/orders
Fax all information to 03 5973 2444
PHH Intake team will contact the referral source within 24/24 of receiving a referral. This contact not only confirms we have received the referral but also assists with determining the priority for assessment.
The Intake nurse may need to discuss with you, the referral source, further aspects regarding care needs to assist in determining the appropriate time frame that a visit is required. The priority criterion includes aspects of symptom management, family supports in place and emotional or spiritual care needs.
The following is how PHH determine their priorities for assessment, which may help you communicate with the client and their family as to how quickly they can expect a visit:
A: To be seen within 24/24 of referral
- Symptoms require urgent attention (physical, psychological, social or spiritual)
- Syringe Driver in Place
- Family appear to be having difficulties managing
B: B: To be seen within 2-5 days of referral
- Symptoms appear to be stable but needing assistance to maintain stability
- No urgent need for equipment
- Family appear to be managing well
- Family /client request
C: C: To be seen within 6-10 days of referral
- Clients condition is stable and family are managing well with no immediate problems
- Family/client request
D: D: Referral not yet ready to be acted upon
- Early referral with the client still in hospital
- Client/family not willing to accept service yet
- Family/client request
End of life goals
- People experience optimal end of life care
- People's pain and symptoms are managed using quality interventions
- People's preferences and values are recognised and respected in their end of life care
- Better support for carers
- People are cared for in their place of choice
- Where possible, people can choose to die in their place of choice
The PHH consultancy service is available to all Residential Aged care facilities (RACF) within our region. There is opportunity for RACF staff to access advice and support for residents experiencing complex or unexpected end of life issues.
Our consult service aims to work with the RACF staff to assess the resident/families and staffs’ current concerns, and assist in developing recommended care plans to assist the staff in achieving improved quality of life for their residents.
PHH supports the implementation of the Commonwealth Government’s Guidelines for a Palliative Approach in Residential Aged Care Facilities, and working with facility nurses to strengthen the palliative approach for all residents.
The process of providing a specialist assessment and recommendations to RACF, also provides opportunity for informal learning by RACF staff and consolidation of general palliative care principles.
A referral for a consult can be made by completing an online referral form and faxing (03 5973 2444) with supporting information to include:
- Current drug charts
- Current Care Plans
- Medical Health Summary
PHH cannot operate in isolation and relies on its professional network for additional support, expertise and access to support resources. This network includes: South Eastern Melbourne Primary Health Network, Frankston Mornington Peninsula Primary Care Partnership, Peninsula Health, RDNS, Southern Metropolitan Region Palliative Care Consortium, Palliative Care Victoria, Department of Health and Human Services.
How can I learn more about palliative care?
For more information on education visit:
For further information on professional resources visit:
For further information for GP’s visit: