WRHA Pallia*ve Care Program February Lori Embleton, Program Director Mike Harlos, Medical Director

Transcription

1 WRHA Pallia*ve Care Program February 2013 Lori Embleton, Program Director Mike Harlos, Medical Director

2 Pallia*ve Care Program Two streams of service delivery: 1. Registra*on on Program 2. Consulta*ve Services

3 REGISTRATION ON PALLIATIVE CARE PROGRAM

4 Registra*on on Program Pa*ents can be registered on the Pallia*ve Care Program if they meet program criteria: Prognosis of less than 6 months No longer receiving aggressive treatment which requires on- going monitoring for and treatment of serious complica*ons Have chosen a comfort- focused approach including a decision to decline auempted resuscita*on

5 Registra*on on Program Once registered with the program, pa*ents are eligible for: Case management through Pallia*ve Care Coordinator Access to Community Pallia*ve Care Nursing 24/7 Pallia*ve Care Nurses have access to Pallia*ve Care Physician Admission to Pallia*ve Care Units (PCU) and Hospice if bed available Enrollment on Provincial Pallia*ve Care Drug Access Program

6 When to Register a Pa*ent on Pallia*ve Care Program Pa*ents are considering going home from acute care Need to plan for services to be in place Pa*ents being transferred to Long Term Care Se]ng

7 How to Register a Pa*ent on PC Program Complete the Applica*on for Registra*on form 2 page form completed forms can be processed more quickly Completed forms are reviewed by PC coordinator Accepts on to Program Rejects applica*on all reviewed by Manager, Program Director or Medical Director

8 Acute Pallia*ve Care Units (PCU) Admission to PCU for symptom issues Physical symptoms Psycho- social distress Caregiver distress Admissions managed centrally by PC program staff Bed management guidelines

9 Acute Pallia*ve Care Units St. Boniface Hospital 15 bed unit Access to ter*ary care services Riverview Health Centre 30 bed unit (2 beds currently closed) Long term care facility

10 Acute Pallia*ve Care Units Once symptoms are controlled, ac*vely discharge to appropriate site Approximately 75% of pa*ents die on PC unit Approximately 20% of pa*ents are discharged home from Pallia*ve Care Units Lack of care op*ons if home not possible PCH Chronic Care Hospice

11 Hospice se]ngs in WRHA Grace Hospice 12 beds in stand alone facility near Grace hospital RN staffing 24/7 Limita*ons in care that can be provided

12 Hospice se]ngs in WRHA Jocelyn House 4 beds in split- level home in St. Vital RN staffing 4 hours a day 5 days a week HCA provide care 24/7

13 Hospice Hospice is appropriate when: Symptoms well controlled Care needs are not complex Prognosis of 1 3 months Pa*ents cannot or do not wish to be cared for in the community

14 Care at Home Majority of pa*ents on Pallia*ve Care program are in the community Pallia*ve pa*ents in community have same service limita*ons as all Home Care clients HCA and PSW services provided by Home Care Program Families/caregivers must be very involved in providing care

15 Northwest 7 Oaks Northeast PCHs PCHs Patients at home Central Patients at home Grace Home PCHs Concordia Community Teams: Community Nurses CNS MD Coordinator Psychosocial Community Clinics PCHs VGH HSC Patients at home Community Clinics Community Clinics South

16 Inter- professional Community Implemen*ng EMR Model Will allow all members of Pallia*ve Care team in community to chart on one char*ng system Will improve informa*on sharing and communica*on between primary care providers (using EMR) and pallia*ve care providers

17 CONSULTATION SERVICES

18 Consulta*ve Services Available to anyone with a life limi*ng illness in any care se]ng for symptom management, psycho- social support or assistance with discharge planning Consulta*on services are provided by inter- professional team members including: Pallia*ve Care Physician Pallia*ve Care Clinical Nurse Specialist Psycho- social Support Specialist

19 When should Pallia*ve Care be consulted? Assistance with symptom issues Managing Physical symptoms MD to MD consults for advice 24/7 Psycho- social Assistance with care planning What might care team expect as pa*ent nears end of life? Will oral route be available? Could symptoms escalate?

20 When should Pallia*ve Care be consulted? Goals of care are not clear Discrepancy between pa*ent, family and/or members of care team with plan of care Discharge to community or LTC is an*cipated Does pa*ent need to be or are they currently registered on Pallia*ve Care program? Would it be appropriate for Pallia*ve Care nurse to see the pa*ent in the community?

21 What informa*on is needed on consult? Main reason for consult What is the main symptom issue? Urgency of consult Is the physician aware of the consult?

22 How to contact Pallia*ve Care Program One number to call if you have ques*ons or need a consulta*on during business hours: Do not page Pallia*ve Care team members directly or leave messages regarding consults on their office phones.

23 How to contact Pallia*ve Care Program Physician to physician consulta*on available 24 hours a day 7 days a week:

24 Consult Service Community Palliative Nursing Case Coordinator Admission Eligibility Medication Coverage aggressive, often toxic treatment focused on cure or life-prolonging disease modification comfort-focused prognosis 6 mo. or less some treatment limitations (DNAR, no TPN, no chemotx with high adverse effects Diagnosis of Life-Limiting Illness Transitioning to Palliative Palliative

25 Increase capacity through education, advocacy, partnerships Palliative Care as a philosophy of care Formal Program