Leading Better Value Care
Local vignette – Nepean Blue Mountains LHD

Renal supportive care

Multidisiplinary clinic – A clinician’s perspective

By Chelsea Jones

28 Apr 2021 Reading time approximately


What is important to know about your service?

The Renal Supportive Care (RSC) service provides home visits and is currently supporting around 100 patients. It covers a vast geographic location of more than 9,000 square kilometres. The goal is to provide supportive care within the home as most patients have difficulty travelling or have limited time for allied health appointments due to so many medical appointments and dialysis.

The primary aim of RSC is to support the patient through their journey, managing them with a biopsychosocial (holistic) model of care to improve patient outcomes and end of life care.

What organisational model do you use?

RSC is a nurse-led model and a multidisciplinary approach.

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?

The RSC involves a multidisciplinary team, including nurses, palliative care physicians, dietitians, social workers, physiotherapists, occupational therapists and clinical psychologists. The team works together to relieve patients’ symptoms and other forms of distress.

A multidisciplinary clinic is available to patients with kidney failure (dialysis, conservative or transplant pathway) who have been referred by their nephrologist. Along with home visits, patients are also supported through clinic and dialysis visits, phone calls, inpatient reviews and case management/family conferences.

Tailored exercise programs are available to patients to maintain/improve function, which aims to prevent deterioration. Home modifications and equipment prescription are also available. This is determined through our allied health home visit assessment.

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?

The service provides education to improve patient knowledge of their condition and to identify ways to best manage their condition and improve quality of life. This includes energy-conservation knowledge, equipment prescription (to ensure they can visit a coffee shop or restaurant with their family), setting up equipment provision, and educating patients and families on moving and handling. This enables patients to be at home, ensures comfort and reduces risk of injury.

What tips do you have for others?

  • Provide in-home services, where possible.
  • A multidisciplinary approach is most effective to holistic patient-centred care.
  • Quality of life is important to consider in assessment/treatment plans of palliative patients.

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