Just in Case Box
Frequently Asked Questions
What is a Just in Case Box?
The Just in Case Box is a more than just a package of prescribed medications and related medical supplies. Patients who are prescribed a Just in Case Box by their General Practitioner also receive the clinical and non-clinical care during the last days of life through tailored “end of life packages” with additional support provided through 24/7 telehealth and/or video link to a Registered Nurse via a Samsung Galaxy Tablet. Lay carers also receive a comprehensive and individualised, one on one education session, provided by trained Registered Nurses, to learn about the safe management of end of life medications using the Caring Safely at Home resources. Additionally, this is fully supported by collaborative and coordinated liaison with the General Practitioner and the patients other health care providers with frequent reporting and communication to ensure continuity of care.
How can I access the reviewed Guidelines?
How can I find out more about the consultation process?
The 2014-2016 consultation report can be accessed here;
Is there really a need for a Just in Case Box in Tasmania?
Six months of hospice@HOME data (Jan 2015-June 2015) were analysed by a team of researchers based at hospice@HOME in July 2015. The data analysis focussed on a cohort of patients who had expressed a preference to die at home but had died in a facility (hospital or hospice, public or private) one week or less following admission. From that cohort it was found that 60% had been admitted for symptom management at end of life. The team then conducted some ‘deep dives’ into that cohort and found that there were many occasions when access to medications had proved difficult, time consuming and distressing. The findings of the hospice@HOME needs analysis was consistent with findings in the literature review from published papers in Australia and overseas.
hospice@HOME have also been consulting widely with stakeholders in Tasmania. Many stakeholders recognise that the only method for patients to access end of life medicines, at low (or no) cost is if Specialist Palliative Care Services are involved in their care. This results in all Level 1 and some Level 2 patients receiving an inequitable service, particularly for those with a preference to die at home. Stakeholders have also stated that end of life medications dispensed by the community pharmacy are expensive and often act as a barrier to accessing end of life medications for those Level 1 and some Level 2 patients. There are continuing state inconsistencies in accessing terminal medications between those who want to manage symptoms at home and those who are able access medications through the hospital system.
Who are the Guidelines designed for?
The Guidelines have been developed with Level 1 and Level 2 (Tasmanian Palliative Service Delivery Model) patients in mind and to assist General Practice to implement a terminal care management plan, as recommended by the Australian and New Zealand Society of Palliative Medicine (ANZSPM) Framework for Palliative Care in the Community Based Aged Care Patients.
hospice@HOME acknowledges that this was not clearly articulated in prior communications and has amended this in the scope, which now reads:
“hospice@HOME patients who are receiving palliative care from their primary care providers and have expressed a preference to die at home. The scope does not extend to Residential Aged Care Facilities.”
For further information please go to:
Are Just in Case Boxes used elsewhere?
Yes, higher income countries such as the United Kingdom, Canada, Sweden and the United States of America use similar medication kits. There is also emerging literature from middle income countries such as India in the use of such items.
The UK (England, Wales, Scotland and Northern Ireland) have implemented The Gold Standards Framework (GSF) Quality Improvement Programme in End of Life Care. These standards state that Palliative Care Emergency Medicine Packs (Just in Case Boxes) are a requirement in the provision of excellence in community based palliative care. In Australia, the ACT has successfully implemented an Emergency Medical Kit and hospice@HOME has worked closely with their lead researchers in the development of the Guidelines. To a lesser or greater degree Queensland, New South Wales and Victoria have similar systems in place.
For further information please see:
Is there any evidence that Just in Case Boxes reduce hospital admissions at end of life?
Research in Canada and Sweden has found that palliative medication kits are a simple and effective way of anticipating and addressing comfort and symptom control for dying patients being cared for in the community. They can avert institutional crisis admissions, extend the period of time patients can be cared for in their homes and they may also increase the likelihood of a home death.
For further information please go to:
Why can’t the patient access the medications from the hospital pharmacy?
Only patients who are under the care of a specialist team can access end of life medications from the hospital pharmacy.
A study in South Australia in 2013 objectively quantified the medication access gap and found that 13% of all community pharmacies do not stock any terminal medications, only 40% stocking midazolam and 50% stocking sub cutaneous morphine. In Tasmania, few community pharmacies stock large supplies (or none) Midazolam and Hydromorphone, with only those servicing Residential Aged Care Facilities stocking a reliable supply of the Australian and New Zealand Society of Palliative Medicine (ANZSPM) medications recommended in the End of Life Symptom Management Medications for Older Australians Living in the Community. This means that uncomplicated end of life patients have to be referred to a hospital service to access end of life medications – a process which is unsustainable and economically inefficient. By increasing access to terminal medications in the community, uncomplicated end of life patients can be able to be cared for by their GP if that is their choice.
For further information please go to:
Why is a single regional community pharmacy being used?
hospice@HOME were advised by the Tasmanian Chief Pharmacist that in the initial implementation phase of the project that there should be one community dispensing pharmacy in each region. This was to ensure a constant supply of in date medications with a clear process for ordering, dispensing, collecting, managing and returning the medications and a clear channel of communication with a patient’s own pharmacy.
It is envisaged that Tasmania will eventually have capacity for a palliative care network in community pharmacies where prescriptions will generally go to a patient’s usual pharmacy, and the pharmacist can knowingly re-direct the prescription or obtain the medications from a network pharmacy if required.
If the patient, carer and/or family do not want to travel to collect the Just in Case Box from the regional pharmacy, hospice@HOME will coordinate pick-up and delivery on their behalf.
Wasn’t the Australian and New Zealand Society of Palliative Medicine list of medications developed for Residential Aged Care Facilities only?
The ANZSPM End of Life Symptom Management Medications for Older Australians Living in the Community released in October 2015 differs slightly from the ANZSPM endorsed list for terminal care in residential aged care in that it addresses concerns typically held by non-paid carers in the home.
For further information please go to:
Are the patient’s family expected to administer the medications?
The Just in Case Box is a patient centred approach which means that it is adaptive in accordance with the strengths and limitations of people with palliative care needs.
Research in Queensland found that the likelihood of patients remaining symptomatically well managed at home usually depends upon input from lay carers who may be required to administer sub cutaneous medications. Bereaved carers report their capacity to provide an injection adds value to patient care; nonetheless, many report the need for education and resources to assist them to confidently manage this aspect of their care-giving role.
The Caring Safely at Home (CSAH) education and resources were developed by Brisbane South Palliative Care Collaboration (BSPCC) in partnership with the Centre for Palliative Care Research and Education (CPCRE) and Blue Care. The purpose of using the CSAH resources is to enhance the capacity and confidence of lay carers to help palliative patients remain at home, with timely access to symptom control, by teaching them to safely and competently deliver sub cutaneous medication.
The Just in Case Box education for lay carers will utilise the full suite of CSAH resources that use a standardised educational framework to ensure that lay carers can manage sub cutaneous injections. Central to this is a time effective, one on one educational session delivered by hospice@HOME Registered Nurses (RNs).
In the one on one education sessions the hospice@HOME RNs will:
- Teach and demonstrate to lay carers how to prepare and administer sub cutaneous injections
- Explain the value of a blunt needle or no needle technique
- Explain the rationale for the insertion of a second subcutaneous cannula
- Explain the need to flush the static cannula with 0.3-0.5mls normal saline after subcutaneous injection(s) given
- Assess that the carer is competent to safely prepare and administer subcutaneous injections.
They will also provide:
- Illustrated step-by-step charts
- A practice demonstration of the injecting device
- Colour coding medication labels
- A colour coded guide for medication
- A caregiver daily medication diary
- A competency checklist
- A Samsung Galaxy Tablet to watch the “Palliative Subcutaneous Medication Administration: A guide for carers” at their convenience
For further information please go to;
Is there any education for GP's and Nurses about the Just in Case Box?
Yes. For GPs we recommend that GPs that they watch the symptom management videos and do the Active Learning Module on the Decision Assist Website. It also a recommendation that they should consider taking on a PEPA placement with the Specialist Palliative Care Service. Places are available and funding is also available at present. Additionally, Deputy Director of Brisbane South Palliative Care Collaborative, Professor Liz Reymond MBBS [Hons], FRACGP, FAChPM, PhD, will be presenting two hour workshops on end of life care and symptom management in Devonport on the 8th November, Launceston on the 9th November and Hobart on the 10th November. The workshops will be available to attend face to face or alternatively via webinar. hospice@HOME also provide seminars and presentations to practices and/or individual GPs at request or GPs can contact their Tasmanian Health service GP Liaison officer for further peer-to-peer support.
For nurses, we offer free online education package which is available here. The online package is supported by 3CPD points on completion of the post education survey. Alternatively, hospice@HOME provide face to face sessions, state-wide on request.
For details of the education please see the flyers below.
What evaluation is being done?
With the limited amount of time we have left to evaluate the initiative, we have to be realistic about what outcomes we can evaluate. The Reference Group felt that there should be a focus on patient/carer experiences, an economic evaluation and the experiences of the multidisciplinary team. As a result, the JiCB Steering Committee have chosen a validation survey called ‘Support Team Assessment Schedule’ (STAS) as the tool to be using for the evaluation of patient, carer and multidisciplinary team experiences. Some of the other evaluation outcome measures are length of time the JiCB was in the home before use, place of death, reasons for transfer (if applicable), length of hospital stay, and use of ED and ambulance services. Please watch this page for any results of the evaluations as they are published.
To see the STAS evaluation questions, please see the link below.
I think that The Just in Case Box shows medical governance and addresses safety issues of who should advise, who should administer and who should not have it – General Practitioner
The Just in Case Box documents are well organised. The two aims of the initiative are very important – Medical Practitioner