Community palliative care (CPC) services provide a comprehensive service to many patients with life limiting conditions. Factors which may challenge traditional community models include responding to same-day requests for admissions, admitting clients who wish to pursue active treatment alongside symptom management and managing patients who have complex treatment plans whose care is still overseen by hospital-based specialists. Another recognised challenge is communication between hospital and community providers, particularly during acute admissions. This is important for optimal transition of care both on admission and when patients return home. In response to these challenges, Monash Health developed a Hospital-In-The-Home Palliative Care (HITH PC) service with dedicated palliative medicine specialist EFT and additional consult support from our RAPID palliative care team. This service aims to overcome deficiencies in traditional models, and support patients to receive specialist palliative care acutely in the community setting when desired.

Our HITH PC model provides outreach care to varied patient cohorts. Our largest cohort includes patients with recurrent pleural effusions and ascites, requiring frequent drainage via indwelling Rocket and PleurX drains. These patients receive regular visits from HITH nursing staff for drainage of pleural effusions and ascites, as well as specialist palliative care which is provided via a telehealth model. Many of these patients are jointly managed with CPC, and their care is discussed at a weekly HITH PC MDT. A second HITH PC model is delivering continuous subcutaneous infusions of palliative care medications when required for optimal symptom management or end of life care. This service supports patients to be discharged from hospital earlier, and avoids unnecessary ED and acute hospital presentations. Deteriorating RACF patients with unstable symptoms can be admitted same-day to our service for urgent assessment and initiation of care, whilst awaiting transition to traditional CPC models. HITH PC is also able to oversee complex cancer pain management, involving opioid rotations or titration guided by palliative medicine in a bed-substitution model of care.

A key initiative is our weekly HITH Palliative Care Multidisciplinary Discussion Team Meeting (MDT). This meeting is attended by medical, nursing and allied health staff from Monash Health HITH and Palliative Care teams, as well as clinical representatives from our regional CPC services. It enables direct and regular discussion of joint clients, to optimise handover and ensure seamless transition of care between services. Having evolved during the COVID-19 pandemic, a period of transformation in community care provision, this meeting is now an established part of our usual care.

To date, our HITH palliative care model has serviced over 320 clients. Interventions such as our MDT have transformed our relationships with CPC partners and improved our transitions in care. We have provided HITH PC to over 200 patients with Rocket/PleurX drains. Our specialised care cohorts have enabled many patients with complex care needs to receive complex interventions and to remain in the community for longer. Our HITH PC service challenges and augments traditional models, to improve care for our community.