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Joan Doran, Program Lead 27 April 2011

Joan Doran, Program Lead 27 April 2011. Overview of HPC Teams Education Project. Working Together to Support Best Practices in Palliative Pain & Symptom Management for LTC Residents. Objectives. Update re HPC Teams Overview of capacity building projects

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Joan Doran, Program Lead 27 April 2011

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  1. Joan Doran, Program Lead27 April 2011 Overview of HPC Teams Education Project Working Together to Support Best Practices in Palliative Pain & Symptom Management for LTC Residents

  2. Objectives Update re HPC Teams Overview of capacity building projects Education for LTC Homes & Community Primary Providers Physician survey Physician liaison with HPC Teams Input re Education Project

  3. Program Background

  4. Program Mandate Assists primary providers in application of the Model to Guide HPC assessment tools & best practice Offers consultation to primary providers about palliative assessment, pain and symptom management In person, By telephone, teleconference, or Through e-mail (MOHLTC, 2006)

  5. Program Mandate Case-based education & mentoring for primary providers Capacity building amongst front-line service providers re delivery of palliative care Links providers with specialized hospice palliative care resources (MOHLTC, 2006)

  6. HPC Teams for Central LHINModel for Hospice Palliative Care Tertiary / Residential Team COMMUN I CA T I ON Informal Team Expert Team Core Team

  7. Advisory Council Dr. Nancy Merrow Dr. Larry Librach Dr. Russell Goldman Evelyn Rosen Joan Doran Anne Grant

  8. Clinical Nurse Consultants

  9. HPC Program Criteria Patients with a progressive, life threatening illness &/or facing end of life issues Primary intent of treatment is palliative whether palliation of disease, palliation of symptoms (physical, psychological, social) Patient & family agree to referral or to consultative support DNR/No Code status is not required for entry onto the program Unmet symptom management needs of all types

  10. Role of the CNC Supporting health care professionals - not replacing the primary providers Professional consultation re PP&SM in the community & LTC Capacity building targeting the knowledge & provision of palliative care

  11. CNC Role Facilitation & education at Interprofessional Rounds Networking with health care teams within each geographical region Leadership in standardizing palliative care practice: EDITH, SRK, In-Home Chart Educational initiatives in Central LHIN

  12. CCO Toolbox Common Tools Isaac Collaborative Care Plans Symptom Management Guidelines

  13. Referral Process Majority of HPCT referrals from CCAC Community nurses or physicians refer directly: telephone or email Nursing agency or LTC can request a CNC for one or more of their staff

  14. Referral Process (cont’d) HPC Teams will admit, reassess immediate needs & contact providers CNC provides consultation report for the physician, CCAC CM, Primary Professional CNC follows the client case with the professional

  15. Referrals and caseloads increasing as awareness of program grows Each contact with a primary provider to provide recommendations re care plan and pain & symptom management Reports on Activity

  16. Home Visits represent in- home consultation with Health Care Professional Home Visits ER Avoidance • ER visits documented by CNC, Visiting Nurse and CCAC • ER ‘visits avoided’ entered into HPC database when CNC consultation prevents patient going to ER for PP&SM

  17. Deaths Place of Preference Collect data on place of death and % who die in place of choice • For patients who identified a place of preference for death in their plan, October 2010– March 2011 85% achieved their goal

  18. Program Hours Core hours, 0830-1630 Mon-Fri After hours on-call available CNCs provide consultation for all health care professionals After Hours Phone: 905-954-5220

  19. Contacting HPC Teams

  20. LTC Home Education Project • Funded by Central LHIN • Provide support to LTC homes in the provision of quality end-of-life care • Increase knowledge transfer for the health care team

  21. Outcomes • Reduction in ER visits • Enhanced Pain and Symptom Management • Enhanced communication with residents/families • Increase utilization of Advance Care Planning

  22. Process • Requested Expression of Interest • Interviewed & selected 4 LTC homes • Representation across LHIN • Gap analysis • Collaborated with NLOT • Developing curriculum • Physician & RN/RPN • PSW

  23. Process (cont) • 4 Sessions • On-line Repository of Resources • Case finding among current residents and case-based mentoring • Program evaluation

  24. Topics • Issues and Challenges in Providing Quality End-of-Life Care • Advance Care Planning • Working with Families • Pain Management and Last Hours

  25. Education • Hired researcher/education assistant • MD/RN/RPN sessions facilitated by palliative care physicians, PC experts, with support from CNC’s • PSW sessions will be led by PalCare

  26. Evaluation • Conduct gap analysis to determine reasons for ER transfers • Chart reviews • Interviews with MD’s, RN, Administration • Based on gap analysis, develop, implement and evaluate intervention for quality EOL care

  27. Feedback?? • What issues do you identify in providing high quality EOL care to LTC residents? • Are palliative patients being sent to ER? Why? • What needs to be in place to support LTC residents to die in their home?

  28. Physician Survey ‘Assessment of Service Provision and Willingness to Engage’ • Developed by Dr Russell Goldman and Dr Camilla Zimmerman – TLCPC/ PMH

  29. Purpose • To determine the level of GP/FP care being provided to community homebound patients

  30. Purpose • To identify the proportion of physicians who provide the following services to homebound palliative patients: • Scheduled home visits • After-hours home visits • Urgent home visits during office hours • 24/7 coverage with after-hours home visits as required

  31. Purpose • To determine what supports would facilitate PCP’s to engage in the care of homebound palliative patients • Develop a registry of PCP’s who would be willing to assume care of patients who do not have access to a FP

  32. Methodology • Survey all FP who have a primary practice address in Central LHIN • Mail out survey/ E mail – (OCFP assisting) • Can complete on-line or mail in survey

  33. Outcomes • Identify barriers to the provision of home palliative care by FP’s • Inform the design of an intervention to improve FP capacity and willingness to provide home based palliative care

  34. Outcomes • Develop a list of FP’s who are willing to take on additional palliative patients • Results will be presented at national and international conferences and published in peer- reviewed journals • Timeline – to be completed within next 6 months

  35. Physician Liaison • Physician roster established to provide 24/7 availability • Provide support to the HCP Teams CNC’s & FP’s to care for patients in community

  36. Questions

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