I drafted a model of Renal Supportive Care, which included an implementation plan, for generalist Palliative Care Needs Rounds.
The Needs Rounds are aimed at clients with End Stage Renal Failure who may be receiving dialysis or conservative management with or without community nursing needs. I consulted with staff including the following: – renal supportive care nephrologist, dialysis nurse unit managers and Palliative Care CNC for Community Nursing.
As the new Digital Health Record is still being built in our respective clinical areas, this is delaying the use of formal tools. Until we can add our tools to this system, the Needs Rounds that have been conducted have been informal allowing us to test and refine our processes.
There is improved communication between teams regarding review of implemented actions and also for sharing of concerns. This has also led to clearer communication regarding medication changes and reviews. There is improved care planning and flexibility to accommodate appointments especially in relation to attending dialysis, wound care and drain management. All of this has improved continuity, coordination and transitions of care.