Leading Better Value Care
Local vignette – Mid-North Coast LHD

Renal supportive care

Multidisiplinary clinic – A clinician’s perspective

By Marilyn Body

28 Apr 2021 Reading time approximately


What is important to know about your service?

Coffs Harbour Health Campus was built in 2001 and is the major referral hospital for the Coffs Network of the Mid North Coast Local Health District. It provides a broad range of specialist services to the residents of Coffs Harbour, Bellingen and Nambucca local government areas. With 292 beds, it provides the majority of the network’s specialist medical and surgical services.

What organisational model do you use?

Multidisciplinary clinic.

Shared decision-making
leads to
Refer to renal supportive care
leads to
Minimising patient suffering
leads to
Ongoing supportive care

What is special about the way care is delivered that is valuable for others to know?

Renal supportive care (RSC) is coordinated through a multidisciplinary team including a social worker, registered nurse, occupational therapist and dietitian with access to nephrologist and palliative care specialists.

Services include consultation with the RSC team, symptom management, coordination of care, advance care planning and nutrition advice. The team is able to visit the patient at home or in the clinic, which enables a holistic approach.

A multidisciplinary clinic is available to patients with a high symptom burden. Referrals are made through the treating nephrologist to the RSC team. Once a referral is received the initial timeline for the first appointment is within a few weeks.

Patients accessing the clinic are supported with a plan of care to improve their quality of life.

A companion document describes options for organisational models in renal support care. One option is a nurse-led model with a multidisciplinary approach. This vignette describes the model from a local perspective.

How does it make a difference?

We can have patients assessed by the palliative care specialist and then support them with any changes in treatment. One example is a patient who has been attending the clinic and is now on the palliative care journey. We are now able to ensure the patient and his family have the support they need, whereas previously there were barriers in referring renal patients to palliative care.

What tips do you have for others?

  • Be patient as it takes time to build relationships with patients and families.
  • Collect data to demonstrate the impact and outcomes of renal supportive care.
  • Follow-up of patients is essential.
  • Be flexible and think outside the box.

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