Supporting Patients and Their Caregivers After-Hours at the End of Life: The Role of Telephone Support

Article Outline

• Abstract
• Introduction
  • Meeting the Palliative Care Needs of Rural and Remote Australia
  • Literature Supporting After-Hours Palliative Care Services
  • Potential Models of After-Hours Intervention in Australia
  • Developing a Local After-Hours Service Delivery Model in a Regional Setting
  • Aim
• Methods
• Results
  • Palliative Care Professionals
  • MPS Nurses
  • General Practitioners
  • Caregivers
  • Management
• Discussion
  • Limitations
• Conclusion
• Acknowledgments
• References
• Copyright

Abstract 

Twenty-four hour access is accepted as a gold standard for palliative care service delivery, yet minimal data exist to justify the cost of this initiative to health care planners and policy makers. Further, there is scant information concerning optimal and efficient methods for delivering after-hours palliative care advice and support, particularly in regional and rural settings. This article reports on an evaluation of a local after-hours telephone support service in regional Australia. A centralized after-hours telephone support service was provided by generalist nurses at a Multipurpose Service in a rural community. A mixed-method evaluation, including semistructured interviews, was undertaken after 20 months of operation. During the period March 31, 2005 until November 15, 2006, 357 patients were registered as part of the Mid North Coast Rural Palliative Care Program. Ten percent of patients or their caregivers accessed the After-Hours Telephone Support Service, representing 55 occasions of service. The most common reason for contacting the service was for reassurance surrounding medication usage, symptom management, and anxiety. This experience demonstrates proof of concept that acceptable palliative care advice can be provided by generalist nurses in a cost-efficient manner. Common patterns emerged in utilization that can assist in service planning and staffing formulae. There is also a need to investigate mechanisms of interfacing with larger scale call centers, to explore the differences within generic and disease-specific approaches, and assess the appropriateness of after-hours telephone support with different cultural groups.

Key Words: After-hours telephone support services, palliative care, health service evaluation, Australia

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Introduction 

Minimizing patient and caregiver distress is a central principle of all palliative care delivery. Being the caregiver of someone dying at home can be a confronting and daunting experience.¹, ² Feelings of isolation and onerous responsibility can be compounded when health care providers are less accessible, particularly, after-hours. No matter how much health care providers endeavor to anticipate their patients’ and families’ needs, there will often be crises, either real or perceived. Many of these events will occur outside of normal working hours, challenging traditional models of health care delivery.³

The majority of larger specialist palliative care services are able to deliver 24-hour coverage, which ensures that patients and their caregivers have ongoing access to information, assistance with decision making, communication, and support. Unfortunately, access to this level of service is variable and particularly limited in rural and remote communities.⁴ A combination of minimal data to convince administrators of the value of 24-hour coverage, limited access to scarce health care resources and workforce issues present numerous challenges for these smaller rural palliative care services.⁵

Meeting the Palliative Care Needs of Rural and Remote Australia 

Australia supports a system of universal health care coverage and there is a mandate to strive for equitable service delivery.⁵ Despite this stance, people in rural and regional Australia do not have the same level of service provision as their urban counterparts.⁶ In Australia, the National Palliative Care Strategy provides a framework for palliative care service development, striving to support the delivery of equitable, effective, and high-quality palliative care across a range of settings.⁷ This policy platform recommends that patients and caregivers have 24-hour access to palliative care services, regardless of their location.⁷ Although this standard is also reflected in many local policy documents,⁸, ⁹ less than half of all rural services in one state have been able to establish and maintain a 24-hour palliative care service.⁸, ¹⁰

The National Rural Palliative Care Program¹⁰ was implemented as part of the National Palliative Care Strategy⁷ to explore approaches to address this disparity in access and outcomes. This initiative aimed to strengthen community partnerships in eight distinct rural and remote demonstration sites in order to enhance the delivery of palliative care locally. A range of strategies have been undertaken to increase the profile of palliative care in these eight rural Australian communities through: enhancing direct care delivery; strengthening the links between specialist palliative care and generalist health care providers; and developing models of care appropriate to the needs of people living in these diverse rural communities.¹⁰

The New South Wales Mid North Coast was one of the eight demonstration sites in the National Rural Palliative Care Program.¹⁰ This regional community has a population of 67,000 and a specialist community-based palliative care service.⁵ Prior to this initiative, the palliative care team, based at the local community hospital, had inadequate workforce resources to provide any level of after-hours palliative care delivery.⁵ This challenge is not unique to this regional area, as many rural Australian palliative care services struggle to achieve 24-hour coverage. This is primarily due to operating in an environment of scarce financial and human resources and needing to service large but sparsely populated geographical areas.¹¹ The allocating of additional funding, as part of the National Rural Palliative Care Program,¹⁰ provided the Mid North Coast community with a unique opportunity to explore creative options to increase after-hours access for palliative care patients and their caregivers.

Literature Supporting After-Hours Palliative Care Services 

Even though providing after-hours care is seen as part of a best practice model⁹ in palliative care, there are little data documenting process and outcomes issues. In Australia, those palliative care services with sufficient resources to provide 24-hour access tend to be part of larger metropolitan academic centers with greater capacity to extend the reach of palliative care.¹¹, ¹² The literature suggests that the level of after-hour service delivery is quite variable and can range from telephone support,¹³, ¹⁴ home visits in response to a call,¹³, ¹⁵ and/or routine after-hours home visits.¹⁵, ¹⁶

In North America, telephone advice has been accepted as an important part of health care services, with telephone protocols and guidelines developed and evaluated. Phone consultation is also becoming part of the training of hospital staff, with many telephone services being staffed largely by registered nurses.¹⁷, ¹⁸ Telephone triage by registered nurses includes: symptom assessment; home treatment advice; referral; information brokering, and crisis intervention. Nurses with specialized training and experience in decision making use approved evidence-based protocols or guidelines and the nursing process (assess, diagnose, treat, and evaluate) to provide information and support. This involves nurses making sound decisions under conditions of uncertainty and often urgency.¹⁹, ²⁰

Both internationally and nationally, health call centers are increasingly recognized as a strategy to provide the community with health care information, advice, and support without time or geographic restrictions.²¹ Health call centers are seen as an important strategy to facilitate equitable access to health care advice²¹ and promoting self-management,²² as well as relieving pressure on acute care services.²³ In the United Kingdom, as part of a broader information access process, the NHS Direct provides the community with access to telephone support on a wide range of health issues.²⁴ Although the efficacy of telephone interventions on a disease-specific basis have been reported in chronic heart failure,²⁵, ²⁶ Worth and colleagues question whether generic services can meet the complex needs associated with palliative and end-of-life care.¹ In addition, the study of Riegel et al.²⁶ demonstrates the difficulties of transferring models between cultural groups,²⁷ suggesting that health call centers may not be effective and acceptable for all cultural groups.

Potential Models of After-Hours Intervention in Australia 

The literature suggests that there are two key approaches to after-hours palliative care service delivery: (1) the use of access to a health professional via remote telephone support and (2) the use of inpatient facilities as a source of advice and support. The first model uses a designated on-call, community-based health care worker, usually assigned to a palliative care or community health team. For example, as part of a demonstration project, a regional service in New South Wales provided a 24-hour call service on a weekly rotational basis between project partners in the public and private sectors.¹⁷ The 1-800 number was diverted to a mobile number or the number of the person rostered to be on-call. This person had the capacity to conduct a home visit if required.¹⁷ A slightly different model has been adopted in Western Australia, where a specialist community-based nursing service is funded by the State Health Departments to provide a 1-800 telephone support service number for nurses throughout the state. This number is diverted to the Palliative Care Clinical Nurse Consultant on duty.¹⁶ In addition, doctors throughout the State have access to a separate 1-800 number that provides 24-hour access to an on-call palliative care physician.¹⁶ This same community-based specialist palliative care service provides palliative care patients and their caregivers with 24-hour access to care, with nurses rostered to respond to emergency calls and routine visits in the metropolitan area.¹⁶

The second model of after-hours palliative care support uses an inpatient palliative care unit or ward as the contact point to receive phone calls. These providers either manage the call themselves or refer the caller to another service.¹⁵, ²⁸ In observational studies, telephone support has been found to be a useful resource for families caring for terminally ill family members as it increases their access to support and is thought to reduce unnecessary admissions to hospital.⁴, ²⁹ An Australian study evaluated an inpatient-based after-hours telephone support service where the majority of calls received during the period were managed by three staff members. There was some predictability of call outcome dependent on the identity of the nurse. This raises the issue of the level of training provided to inpatient staff to triage and manage cases over the phone.¹⁵

Developing a Local After-Hours Service Delivery Model in a Regional Setting 

The Mid North Coast Rural Palliative Care Project Team examined a range of potential models to determine feasibility (Table 1). After considering a range of approaches, it was decided to establish the After-Hours Telephone Support Service (AHTSS) at a local Multipurpose Service (MPS) for a 20-month trial period from the March 31, 2005 until December 31, 2006. An MPS is a Commonwealth Government initiative to increase small rural and remote communities' access to a flexible mix and range of primary health care, acute care, aged care, and palliation services.³⁰

Table 1. Published Studies Describing After-Hours Telephone Support

GP=general practitioner.

The Western Victorian Division of General Practice Nurse Telephone Triage After-Hours Service Delivery Model underpinned the establishment of the local service.³¹Although this model was essentially established to reduce general practitioner call out, many elements were applicable to the Rural Palliative Care Project, particularly the quality improvement components, flow charts, documentation templates, and guiding principles.³¹, ³²

In addition to contacting a health professional after-hours, there also needs to be a mechanism for accessing appropriate and relevant information to support clinical decision making. This information can range from paper-based systems, patient-held clinical records, and faxed handover sheets to complex state-of-the-art, point-of-care, clinical information systems. As part of the MidNorth Coast Rural Palliative Care Project, the Palliative Care Clinical Information System (PalCIS)³² was used. Briefly, this system is a secure, patient-focused, electronic health record that has been designed for use by teams of health care providers.³²

Following a process of key stakeholder consultations and the consideration of potential options, a Memorandum of Understanding was developed between the Mid North Coast Division of General Practice and a local MPS.³³ A comprehensive procedure manual was developed based upon evidence-based guidelines.³³ The AHTSS was made available to all palliative care patients registered with the local specialist Palliative Care Team based at the regional health campus. In addition, veterans whose palliative care was coordinated by a local private home-nursing service were provided with access to the AHTSS. This after-hours telephone service operated for 365 days per year from 1700 hours until 0830 hours.

Registered nurses at the MPS were provided with structured after-hours telephone support service education, a procedure manual,³³ and relevant document templates. At all times, the staff at the MPS had access to accurate and real-time patient information via PalCIS,³² which was available on the health service intranet. Figure 1 provides an overview of the decision-making process followed by the AHTSS.

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• Fig. 1 

  Decision-making flow chart for AHTSS. RN=registered nurse; GP=general practitioner; AHTSS=After-Hours Telephone Support Service.

Aim 

This 20-month trial of the AHTSS based at an MPS in regional Australia sought to:

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Methods 

A final evaluation of the AHTSS provided by the MPS allowed feedback from all stakeholders.³⁴ This approach was selected because of its flexibility, collaborative potential, and to gain insights into stakeholder acceptability of the after-hours telephone service. This evaluation was undertaken in November 2006 using a mixed-method design, with data being captured from (1) key informant consultation of administrator and policy makers; (2) a review of case notes; (3) interviews of specialist palliative care providers, general practitioners, family members, and generalist nurses involved in service provision and access; (4) minutes and documentation of the rural palliative care project meetings; (5) review of quality assurance activities; and (6) audit of the call sheets.

Approval for the study was obtained from a university and an area health service human research ethics committee. A letter was sent to all participants who had used the service, informing them that the evaluation team would be making contact to seek their feedback about the AHTSS. Participants were provided with verbal and printed information relating to consent, confidentiality, and withdrawal from the study before consent was obtained.

A review of the case notes guided the development of the interview questions, which focused on participants’ expectations of the AHTSS; their perceptions of the quality of the information provided; the effectiveness of the after-hours delivery mode; and suggestions for improvement. Data collection via interviews and analysis was undertaken concurrently as reflexive activities, using thematic content analysis³⁵, ³⁶ to highlight significant themes or concepts. At the end of each interview, clarification was sought from the participants about the content and the key messages a rising from the discussion. A report of each interview was prepared immediately and shared with the evaluation team. This assisted with identifying and reaching consensus on recurring patterns and common themes. Subsequent interviews allowed for exploration of themes emerging from initial interviews.

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Results 

During the period March 31, 2005 until November 15, 2006, 350 patients were registered with the Mid North Coast Rural Palliative Care Project. Few patients identified as being from a culturally and linguistically diverse background (CALD) (n=6) or as Australian Aboriginal (n=2). During this period, 35 (10%) patients and/or their families accessed the AHTSS, representing 55 occasions of service. In 20% (n=7) of cases, the patient accessed the service, whereas in 80% (n=28), the service was accessed by a caregiver. The average duration of the call was 12.35±6.33 minutes. Nurses operating the call center estimated the total time for an occasion of service, including documentation and follow-up, to be 30 minutes. The majority of calls (78%) occurred in the evening between 6 pm and midnight. Based on the number of calls and nursing and administrative costs, this after-hours telephone support service cost less than $3,000 per year to operate within an existing service model.

In the vast majority of cases, issues identified by the patient and their family could be resolved over the phone. Only two patients (6%) were referred to the Emergency Department in the absence of an on-call outreach palliative care service. The major reason for accessing the service was for reassurance surrounding medication usage (Fig. 2). No adverse events or complaints were reported as a consequence of access to the telephone advice.

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• Fig. 2 

  Reasons for accessing the AHTSS.

An audit of the call sheets revealed a high level of adherence with the call protocol sheets (98%). A summary of the findings from the interviews is presented below according to key informant group: palliative care professionals, nurses, general practitioners, and caregivers.

Palliative Care Professionals 

Palliative care professionals perceived an after-hours service as being “worthwhile and useful.” Not only did these clinicians see this as being “extremely valuable for clients to have,” but it also assisted in maximizing the specialist teams’ capacity to better meet their patients and families needs, minimizing their sense of frustration. One staff member commented that the introduction of the AHTSS allowed “better options” to support patients and their families and that it was “critical to have a point of contact.” Staff conveyed their admiration for the after-hours nurses’ capacity to problem solve and think laterally to ensure that patient and caregiver needs were effectively addressed. It was suggested that nurses working within an MPS had unique nursing competencies that enabled them to deliver a range of high-quality nursing services across a number of specialist areas, ranging from emergency care to aged and palliative care. In addition, these nurses have a comprehensive understanding of generalist primary care. It was perceived that this unique skill set enabled these MPS generalist nurses to provide effective telephone advice and support to patients and caregivers in this regional community setting.

MPS Nurses 

The registered nurses providing the after-hours service found that they settled into the role after a period of orientation and adjustment to accessing information via the electronic patient record. They found the “early days were quite difficult” as they adjusted to a process of telephone triage in which they did not know the patient, in contrast to their usual experience, during which they could obtain “inside knowledge of people” in their immediate local community. This process of integrating an additional role into their already multifaceted practice was also initially quite stressful for staff. Nurses felt that although they were in the initial stages dependent on the clinical data from the PalCIS, as they became more confident they became more focused on using their comprehensive nursing assessment skills to identify issues disclosed by patients and their families. These nurses found that the protocols developed for the after-hour's telephone support service were very useful in the provision of relevant nursing advice. One nurse commented: “The protocols are fantastic.”

Their responses and attitudes reflected their depth and wide range of clinical skills and knowledge of local resources. For the most part, these nurses considered that patients and their caregivers primarily called for reassurance, support, and advice. One nurse commented: “They just don't want to go to hospital.” Sometimes staff felt frustrated as they felt they could not adequately meet all patients’ or families’ needs via this remote mode of clinical interaction. However, these perceptions were not reflected in the carer interviews and client feedback.

General Practitioners 

The Mid North Coast Division of General Practice considers that having access to a central point of contact is optimal in accessing not only clinical information but also timely and effective support and advice for patients and families. One general practitioner commented that it is “enormously helpful”…“some people will just suffer in silence not wanting to bother the doctor after-hours… this is a great solution.”

Participants described that the after-hours telephone support service provided support to general practitioners and assisted them in the management of their patients. This is particularly the case if it facilitates access to advice and services in the absence of general practitioner availability. During the project period, there were no complaints from general practitioners related to the advice given by the AHTSS. The comprehensive policy documents and standardized operating procedures helped mitigate this potential risk and increased the general practitioner's confidence in the viability of the system.

Caregivers 

By the time this evaluation was undertaken, all of the patients who had accessed the AHTSS were deceased. Interviews were undertaken with all caregivers (n=8) who could still be contacted at their last known address. Overwhelmingly, the comments from carers accessing the service were complimentary. The only negative comments received in the eight interviews related to a death that subsequently occurred in an acute hospital setting.

Many caregivers saw the AHTSS as a vital lifeline that helped to reduce the sense of isolation experienced at night: “It relieved me to know there was someone to talk to” and “The nights and the weekends are the scariest…you can feel very alone.” For some caregivers, the knowledge that this after-hours service was available was an additional and valued form of support: “They were like family (nurses)…I have no family here” and another person commented: “As long as that lifeline was there I felt I could do it (continue caring).”

The advice and support provided by the nurses helped these caregivers manage the complex process of caring for a dying family member at home, as depicted in the following excerpts:

“It helped me in a big way. They reassured me.”

“You know they tell you everything, you have the information but when you go to do it, it is really scary. It was so good to have someone just telling me I was doing the right thing.”

Many carers faced not only the emotional burden of caring for a dying family member but the added responsibility of needing to assume a clinical decision making role, particularly around medication management:

“Well, I think we just got the tablets mixed up and my wife went hysterical, she was so scared and I just felt awful…we called (the Multipurpose Service) and they sorted it all out…they just talked her down…it was all alright… they called back in half an hour to check up on us…they were wonderful.”

Having access to the AHTSS enabled many caregivers to provide the care that their family members wanted:

“I would never have chosen to do what I did and I am not sure I would do it again, but that was what Mum wanted… she didn't want to go to hospital, she wanted to die at home…but that was so hard for me…especially afterwards… having someone there was such a relief… I gave the needle and I think she may have already been dead…it was such a relief to have someone talk me through.”

For some carers, being able to phone and share with the health care provider that the patient had died was symbolic in terms of acknowledging the person's death:

“When he died, I knew what I had to do…but I felt it was important to let the palliative care service know…you know, they were there for us, that was important. The service was really wonderful.”

Management 

Although all people interviewed acknowledged the benefit of the AHTSS and the excellent job undertaken by the MPS, issues were raised as to sustainability and integration in usual care service provision. It was identified that there are a range of health care professionals on call in the Area Health Service and there are potentials for integration of services for greater synergies and efficiencies. It was suggested that there was scope to explore the notion of having a single point of contact for all after-hours palliative care support across the entire Area Health Service and not just restricting it to several local government areas. However, this would require negotiation, appropriate allocation of resources, and mapping out of protocols.

The cost-effective proof of concept demonstrated in this project in the delivery of acceptable and effective advice by nonspecialist service providers provides confidence for the extrapolation of this model to other conditions. Managers interviewed for this study stated that they would be more reassured with the incorporation of this type of service if they were confident concerning future service demands and expectations, particularly in relation to expanded cancer services.

Several managers saw the sustainability of an automated clinical information system being a barrier to ongoing implementation of the AHTSS. Of interest, the nurses saw this as less of a barrier as they used their clinical decision-making skills, related to the specific issues raised by the caller. In contrast, they saw the protocols as being integral and invaluable. Of note, many palliative care services use an on-call mechanism that does not have access to point of contact clinical information systems. In spite of this, the development of electronic health records will clearly be an enabling factor for telephone support services. The provision of effective protocols, clearly defined scope of practice and decision algorithms mitigates the risks associated with the inability to access clinical records.

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Discussion 

The trend in this evaluation and other published studies indicates that the majority of after-hours palliative care calls occur between 6 pm and 11 pm. This knowledge needs to be used to facilitate appropriate staffing arrangements for after-hours palliative care services.¹⁵, ²⁸ Our findings resonate with other researchers who have found that carers' feelings of uncertainty and anxiety are attenuated after-hours,³⁷ and that providers need to develop and identify process issues in care models.³⁸ Further, there is a need to further develop strategies to promote cross-sector communication, particularly between primary and specialist palliative care providers. In addition, there is need for ongoing education, support, and guidance for the health professional providing the after-hours telephone advice.

The low utilization rates of the after-hours services and absence of on-call costs suggest that the MPS Model is an efficient and effective strategy not only in alleviating distress of patients and caregivers but also in avoiding hospitalization and emergency department presentations. These rates are suggestive of effective care planning by the specialist palliative care team and it is potentially unlikely that utilization rates will increase substantially if this high level of care planning persists. However, this proposed trend requires further exploration.

The increased focus on home-based palliative care on the Mid North Coast and introduction of care planning items under the Medical Benefits Scheme³⁹ are suggestive that proactive community-based care will likely increase rather than decrease in this community. This trend is amplified by a range of factors, such as consumer-based choice demonstrated in this review, policy initiatives, and a drive to decrease pressure on the acute care sector.

A range of initiatives is currently being undertaken in Australia to look at the use of telephone support services. The National Health Call Centre Network will be established as a company jointly owned by the Commonwealth and the States and Territories. This service is expected to start taking calls by July 2007, with an expectation that national coverage will be achieved within four years.²³ Existing State and Territory-based health call centers will transition to the National Health Call Centre Network according to an agreed schedule, which will be developed as part of the implementation planning.²³ The development of this national initiative has implications for enhancing the coverage of 24-hour palliative care telephone support and advice to regional Australia.

Limitations 

There are a number of limitations associated with this evaluation. First, the small sample size precludes drawing definite conclusions about the effectiveness of this intervention for larger populations. Second, the exploration of the perceptions of carers who had not used the service may have yielded some important and useful insights into the low call rates. Third, the number of patients cared for by the specialist palliative care team from culturally and linguistically diverse backgrounds was very low and reflects the demographics of this regional Australian community.⁴⁰, ⁴¹ The area's higher than State average of Australian Aboriginals⁴¹ living in this community is not reflected in the palliative care admission rates nor in the utilization of the AHTSS. This precludes drawing conclusions about the acceptability of this model for Australian Aboriginals and people from culturally and linguistically diverse groups.

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Conclusion 

On the basis of this evaluation and the extant literature, it would appear that access to a palliative care after-hour telephone support service is highly valued, particularly by caregivers. Further, in spite of the absence of robust, high level evidence for after-hours services, some common themes emerge to inform service delivery. The majority of after-hours calls occur in the time from 6 pm to midnight and caregivers value support and advice given by health professionals. Importantly, it appears that the telephone is a suitable vehicle to provide this type of health care service. However, to convince policy makers and administrators of the value of this medium, we need high-level evidence to make a convincing argument for this approach for underserved rural communities. Further, there is a need for palliative care providers to investigate mechanisms of interfacing with larger scale telephone support call centers, to explore the differences within generic and disease-specific approaches, and assess the cultural appropriateness of this model of intervention in culturally diverse groups.

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Acknowledgments 

The research team would like to acknowledge the funding body, the Australian Commonwealth Department of Health and Ageing's National Rural Palliative Care Program. They would also like to recognize the contribution and support of the Mid North Coast (NSW) Division of General Practice, and Prof. Kate White who provided the education and the generous participation of the nurses working at Dorrigo Multipurpose Service. At the time of this study, Jane Phillips was the Rural Palliative Care Project Coordinator, Mid North Coast (NSW) Division of General Practice.

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References 

1. Worth A, Boyd K, Kendall M, et al. Out-of-hours palliative care: a qualitative study of cancer patients, carers and professionals. Br J Gen Pract. 2006;56(522):6–13
   • View In Article
   • MEDLINE
2. King N, Bell D, Thomas K. Family carers' experiences of out-of-hours community palliative care: a qualitative study. Int J Palliat Nurs. 2004;10(2):76–83
   • View In Article
   • MEDLINE
3. Thomas K. Out-of-hours palliative care—bridging the gap. Eur J Palliat Care. 2000;7(1):22–25
   • View In Article
4. Wilkes L, While K, Kristjanson L, et al. Evaluation of an after hours telephone support service for rural palliative care patients and their families: a pilot study. Aust J Rural Health. 2004;12(3):95–98
   • View In Article
   • MEDLINE
   • CrossRef
5. Phillips J, Davidson P, Kristjanson L, et al. Palliative care delivery in regional New South Wales Australia: a review of service delivery models. Aust Health Rev. 2006;30(3):370–379
   • View In Article
   • MEDLINE
   • CrossRef
6. Buikstra E, Pearce S, Hegney D, Fallon T. SEAM—improving the quality of palliative care in regional Toowoomba, Australia: lessons learned. Rural Remote Health. 2006;6(1):1–10
   • View In Article
7. Commonwealth Department of Health & Aged Care. National Palliative Care Strategy, Commonwealth Department of Health & Aged Care. Canberra, ACT, 2000.
   • View In Article
8. NSW Health. New South Wales Palliative Care Framework. A guide for the provision of palliative care in NSW. NSW Health, Sydney, NSW, 2001.
   • View In Article
9. Palliative Care Australia. Standards for providing quality palliative care for all Australians. Palliative Care Australia Canberra, ACT, 2005.
   • View In Article
10. Australian Divisions of General Practice. (2004). Rural Palliative Care Program. http://www.adgp.com.au/site/index.cfm?display-683 1 December 2006. Accessed April 22, 2004.
    • View In Article
11. Palliative Care Australia. Palliative care service provision in Australia: A planning guide. Palliative Care Australia, Canberra, ACT, 2003.
    • View In Article
12. Palliative Care Australia. A guide to palliative care service development: A population based approach. Canberra, ACT, 2005.
    • View In Article
13. Wilkes L, Mohan S, White K, Smith H. Evaluation of an after hours telephone support service for rural palliative care patients and their families: a pilot study. Aust J Rural Health. 2004;12(3):95–98
    • View In Article
    • MEDLINE
    • CrossRef
14. Aranda S, Hayman-White K, Devilee L, O'Connor M, Bence G. Inpatient hospice triage of ‘after-hours’ calls to a community palliative care service. Int J Palliat Nurs. 2001;7(5):214–220
    • View In Article
    • MEDLINE
15. Silver Chain Hospice Care Service . Available at http://www.silverchain.org.au/silverchain/asp/services_services_pallativecare.aspAccessed April 8, 2007
    • View In Article
16. Hatton I, McDonald K, Nancarrow L, Fletcher K. The Griffith Area Palliative Care Service: a pilot project. Aust Health Rev. 2003;26(2):11–18
    • View In Article
    • MEDLINE
    • CrossRef
17. Poole SR, Schmitt BD, Carruth T, Peterson-Smith A, Slusarski M. After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics. 1993;92(5):670–679
    • View In Article
    • MEDLINE
18. Schwartz F, Genovese L, Devitt K, Gottlieb T. Multisite regional telephone care. Nurs Clin North Am. 2000;35(2):527–539
    • View In Article
    • MEDLINE
19. O'Cathain A, Sampson FC, Munro JF, Thomas KJ, Nicholl JP. Nurses' views of using computerized decision support software in NHS Direct. J Adv Nurs. 2004;45(3):280–286
    • View In Article
    • MEDLINE
    • CrossRef
20. Bashshur RL, Reardon TG, Shannon GW. Telemedicine: a new health care delivery system. Annu Rev Public Health. 2000;21:613–637
    • View In Article
    • MEDLINE
    • CrossRef
21. Blixen CE, Bramstedt KA, Hammel JP, Tilley BC. A pilot study of health education via a nurse-run telephone self-management programme for elderly people with osteoarthritis. J Telemed Telecare. 2004;10(1):44–49
    • View In Article
    • MEDLINE
    • CrossRef
22. Munro J, Nicholl J, O'Cathain A, Knowles E. Impact of NHS direct on demand for immediate care: observational study. BMJ. 2000;321(7254):150–153
    • View In Article
    • MEDLINE
    • CrossRef
23. Australian Government Department of Health and Ageing (2006). National Health Call Centre Network. Available at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/national-health-call-centre-network-taskforce-overview. Accessed April 6, 2007.
    • View In Article
24. NHS. NHS Direct (2004). http://www.nhsdirect.nhs.uk. Accessed April 6, 2007.
    • View In Article
25. GESICA Investigators . Randomised trial of telephone intervention in chronic heart failure: DIAL trial. BMJ. 2005;331(7514):425–429
    • View In Article
    • CrossRef
26. Riegel B, Carlson B, Kopp Z, et al. Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Arch Intern Med. 2002;162(6):705–712
    • View In Article
    • MEDLINE
    • CrossRef
27. Riegel B, Carlson B, Glaser D, Romero T. Randomized controlled trial of telephone case management in hispanics of Mexican origin with heart failure. J Card Fail. 2006;12(3):211–219
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (168 KB)
    • CrossRef
28. Baldry C, Balmer S. Clinical audit. An audit of out-of-hours advice services provided by hospice staff. Int J Palliat Nurs. 2000;6(7):352–356
    • View In Article
    • MEDLINE
29. Sach J. Issues for palliative care in rural Australia. Collegian. 1997;4(3):22–27
    • View In Article
    • Abstract
    • Full-Text PDF (391 KB)
    • CrossRef
30. Australian Government Department of Health and Ageing . Multipurpose Services. Available at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/ruralhealth-services-mps.htm2004;Accessed April 20, 2007
    • View In Article
31. West Victorian Division of General Practice Inc . Nurse telephone triage after hours service delivery. Available at www.westvicdiv.asn.auAccessed March 28, 2007
    • View In Article
32. Palliative Care Clinical Information System . Available at http://www.palcis.com/Accessed April 9, 2007
    • View In Article
33. Mid North Coast Division of General Practice . Palliative Care After-Hours Telephone Support manual. Available at http://www.agpn.com.au/client_images/99131.pdf2005;Accessed July 13, 2007
    • View In Article
34. Ward P. 360 degree feedback. London: Chartered Institute of Personnel and Development; 1997;
    • View In Article
35. Miles MB, Huberman AM. Qualitative data analysis. An expanded sourcebook. 2nd ed.. Thousand Oaks, CA: Sage Publications; 1994;
    • View In Article
36. Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Educ Today. 1991;11(6):461–466
    • View In Article
    • MEDLINE
    • CrossRef
37. King N, Thomas K, Bell D. An out of hours protocol for community palliative care: Practitioners' perspectives. Int J Palliat Nurs. 2003;9(7):277–282
    • View In Article
    • MEDLINE
38. Kerr C, Hawker S, Payne S, Lloyd-Williams M, Seamark D. Out-of-hours medical cover in community hospitals: implications for palliative care. Int J Palliat Nurs. 2006;12(2):75–80
    • View In Article
    • MEDLINE
39. Australian Government Department of Health and Ageing . Medicare Benefits Schedule Book. Canberra, ACT: Australian Government Department of Health and Ageing; 2004;
    • View In Article
40. Department of Infrastructure Planning and Natural Resources . New South Wales state and regional population projections. Sydney: Transport and Population Data Centre; 2004;
    • View In Article
41. Public Health Information Development Unit . Population health profile of the Mid North Coast Division of General Practice. Adelaide: Public Health Information Development Unit; 2005;
    • View In Article
42. Hatcliffe S, Smith P. Open all hours. Health Serv J. 1997;107(5559):40–41
    • View In Article
43. Turner VF, Bentley PJ, Hodgson SA, et al. Telephone triage in Western Australia. Med J Aust. 2002;176(3):100–103
    • View In Article
    • MEDLINE
44. Guigou D. Changing practice. Palliative care: only a phone call away. Eur J Palliat Care. 2002;9(3):116–118
    • View In Article
45. Lloyd-Williams M, Rashid A. An analysis of calls to an out-of-hours palliative care advice line. Public Health. 2003;117(2):125–127
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (60 KB)
    • CrossRef