Geographic Complex Assessment and Treatment Service

Transcription

1 Geographic Complex Assessment and Treatment Service A comprehensive approach to palliative and end of life care in Supportive Living. Julia Arsenault, BScN, RN, MAHSR, NP Yvonne Appah, BScN, RN, MN, NP October 27, 2014

2 Conflict of Interest Statement Presenter/Faculty: Julia Arsenault, Alberta Health Services Yvonne Appah, Alberta Health Services There are no relationships that pose a conflict of interest to declare AND this program has been developed without support from commercial entities. 2

3 Outline Overview of Supportive Living Client Population Geographical Complex Assessment and Treatment Service (GCATS) History Team Members Referral Process Case Example Additional Resources Outcomes 3

4 Supportive Living- Edmonton funded spaces Contracted Operators Designated Assisted Living Sites Family Care Homes; Special Care Homes 4

5 History Health Quality Council of Alberta (HQCA) recommendation Development of an integrated service delivery model to improve quality of care, support PEOL clients in their community setting and prevent, where feasible, the transfer of these clients to Emergency Departments (HCQA, 2012) 5

6 Overview Geographical Complex Assessment and Treatment Service Multidisciplinary Team North and South geographical territories Referral based/consult service Urgent response (within 24 hours) 6

7 Team Members Core Team: Social Worker Occupational Therapist Registered Nurse Nurse Practitioner On consult basis: Registered Dietician Speech Language Pathologist Physiotherapist Kinesiologist Enterostomal Therapist Respiratory Therapist Recreation Therapist 7

8 Referral Process Referral Source: Case Managers (main referral source) Systems Case Managers Primary Care Physicians Interdisciplinary Team Members Management Triage/Intake Process 8

9 Referral Process Referral criteria: Complex assessment required Client status/situation not improving with current services Client at risk for multiple ER visit or acute care admission Automatic Referral Triggers: Potential for alternate level of care Palliative/end of life clients 9

10 Palliative End of Life Care Palliative/end-of-life (PEOL) clients are a complex population requiring timely access to coordinated healthcare. GCATS Aim To provide support for clients, families, physicians, Case Managers, and SL operators to successfully care for PEOL clients in their current living environment. 10

11 GCATS and PEOL Clients 1. Identification of PEOL client in SL 2. Automatic Trigger for GCATS Referral 3. Multidisciplinary Team Assessment 4. Development of holistic palliative care plan 5. Ongoing support through palliation 11

12 PEOL Client Identification in SL Meditech Client Grouping Decision Tree Progressive, life-limiting illness Does the client have a progressive, life-limiting illness where death is anticipated within 6 months? 12

13 Automatic Trigger for GCATS Referral Consulted to assess all SL clients with a progressive, life-limiting illness in their home. Cancer and non-cancer diagnoses dementia, heart disease, pulmonary disease, and mental illness. Manages a palliative treatment plan that is holistic and client-centered. ~30% of GCATS referrals are for PEOL Care 13

14 Multidisciplinary Team Assessment Multidisciplinary Assessment within 24 hours: NP/RN- Comprehensive, holistic medical and nursing assessments OT- Mobility and Functional assessments SW- Psychosocial, Financial and Legal assessments 14

15 Multidisciplinary Team Assessment Focused palliative care assessment tools ESAS-r: Edmonton Symptom Assessment System Revised PPS: Palliative Performance Scale ECS-CP: Edmonton Classification System for Cancer Pain MMSE: Mini Mental Status Examination GDS: Geriatric Depression Scale CAGE Questionnaire 15

16 Development of Holistic Palliative Care Plan Family Case Conference Advanced Care Planning/Goals of Care Designation Symptom Management Equipment (i.e. hospital bed) Alberta Blue Cross Palliative Care Drug Coverage Operator staff education and support 16

17 Ongoing Support Human Resources- Added Care After-hours support Community Care Access EMS Palliative Care and Treat in Place Expected Death in Home Template Collaborate with and refer to EZPCP for Symptom Management and/or Hospice Assessment as needed 17

18 Case Example 99 year old female, secure living facility sustains unwitnessed fall and is sent to ER via EMS. Diagnosis: subdural bleed Discharged home for compassionate care 18

19 Case Example Palliative symptom assessments Family Case Conference GOCD completed- C2; Funeral arrangements OT: Hospital bed, pressure relieving mattress obtained Urgent PT consult Spiritual Care involvement Social Work consult Collaboration with Primary Care Physician Site staff education/support Peaceful home death with family at bedside 19

20 Additional Resources Emergency Medical Services and Continuing Care Palliative and End of Life Care and Treat in Place 20

21 GCATS- Outcomes Formal evaluation currently underway Streamlined communication between clients, families, physicians, and various service providers. Increased client and family satisfaction. Improved operator staff confidence in providing PEOL care in Supportive Living. Reduction in hospice utilization from SL Decline in unnecessary ER visits in the PEOL client population 21

22 Summary A responsive, interdisciplinary team within SL can optimize care for PEOL clients by providing timely management of progressive, life-limiting illnesses. This allows PEOL clients who wish to remain in place, the ability to access services that promote comfort and dignity within their home environment. 22

23 Questions? 23