Concerns about the growing number of AIDS patients in the UGU South District of KwaZulu-Natal resulted in the development of an Integrated Community-Based Home Care model (ICHC). Primary health care clinics, Hospice, Murchison Hospital, AIDS organizations and the local community are all involved in the programme.
Innovation: In 2001 the hospital Palliative AIDS team was established to improve the continuum of care for patients and their families and to reduce the hospitalization time. The hospital PAT team includes a doctor, senior nurse, counselor and social worker. On admission patients are interviewed by PAT while their relatives are still with them. This brings the families into the care-loop from the outset. PAT then takes over management of advanced AIDS patients. Patients and relatives are seen by the same team until discharge. On discharge the patients are transferred to the Hospice care-givers who bring the patients into the ICHC project. This approach ensures that patients receive regular medical, social and spiritual counseling, as they are seen at home by community care-givers and health care professionals from Hospice.
Poverty Impact: The Hospice team consists of medical back-up, professional nurses and social workers. The success of the programme is based on the close collaboration between the government hospital, its satellite clinics, NGO's and the community. There has been a positive impact on staff moral and the patients suffer less stigmatization from the community.
Sustainability: The project estimates that it currently reaches 60% of the HIV positive population in the region. The project has resulted in improved family and patient satisfaction with care received, a reduction hospital admissions and a reduction of time spent in hospital. During July of 2001 the project reached 1350 patients and families. PAT results from re-arranging the existing duties of hospital staff, however additional funding is essential for the ICHC component. To date Hospice has secured both local and international funding and they hope to bring the Department of Health's HIV/AIDS Directorate on board.
Replication: There are approximately 50 registered Hospice Associations and many home-based care programmes which could be upgraded to provide quality palliative care.