MH LHIN Palliative Care Initiative. Dr. Robert Sauls September 2010

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Marcia Palmer
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1 MH LHIN Palliative Care Initiative Dr. Robert Sauls September

2 BACKGROUND

3 Mississauga Halton LHIN: Acute care LOS for palliative care 17, 722 days ALC palliative care 1,992 days 19, 714 days (60 beds) Discharges Deceased 62.3% Home 24.1% CCC 12.5% Other 1.1% 3

4 Enhancing Family Physician Capacity Project in Niagara region to support family physicians providing palliative care to their patients Early identification and enrollment Enhanced Palliative Care Team (24/7) Education and decision support 93% of patients expressed a wish to die at home Prior to the project 28% died at home At completion of project - 59% died at home Marshall D. Can Fam Physician 2008;54:

5 End-of-Life Homecare Study (Ontario) Investigated the relationship between CCAC services and utilization of acute care services in the 2 weeks prior to death ER visits Acute care admission Death in hospital Patient selection 9018 deceased patients across Ontario Admitted to CCAC between Apr 1,05 Dec 31,06 Receiving CCAC services for at least 2 weeks prior to death 5

6 End-of-Life Homecare Study (Ontario) Outcomes Earlier admission to CCAC significantly reduced the likelihood of ER visit, hospital admission and death in hospital Increasing nursing hours/wk and PSW hours/week significantly reduced the likelihood of ER visit, hospital admission and death in hospital Seow H. Medical Care 2010; 48:

7 July Oct 2009 Palliative Care Model Development

8 Key Objectives To enhance community capacity to provide palliative care at home in order to: To reduce the ER visits, hospital admissions, and length of stay in hospital To reduce the number of deaths of palliative patients occurring in hospital 8

9 9

10 Key recommendations Improve access Early identification and enrollment with CCAC Improve service capacity Increased nursing and PSW hours Access to APN in the community Engagement of family physicians as part of the team Improve coordination Establish Care Coordinator Establish common care pathways Improve communication between care providers 10

11 Dec 2009 to present PLANNING AND IMPLEMENTATION

12 Early activities Establishment of co-leadership for project MH CCAC & Trillium Health Centre Establishment of Palliative Initiatives Team Project management team Establishment of working groups Retrospective chart audit CCAC Increased nursing/psw hours Increased Palliative Care Case Managers Introduction of APN role 12

13 Working Groups Care Paths Measurement and Evaluation Advanced Care Planning Resource Guide/Education/Communication Electronic Portal Development 13

14 Care Paths 1. Patient discharged from hospital (inpt/er) 2. Patient at home/alc transferred to hospital 3. New patient admitted to CCAC palliative care program 4. Routine care 5. End-of-life care 6. Bereavement

15 Patient Discharged from Hospital

16 PILOT: EARLY IDENTIFICATION TO ROUTINE CARE

Hospital Process Summary VERSION: JULY 30, 2010 Patient Identification Patient Education and Consent Discharge Planning 1 2 3 Any team member Identify eligible palliative patients during bullet

17 Hospital Process Summary VERSION: JULY 30, 2010 Patient Identification Patient Education and Consent Discharge Planning Any team member Identify eligible palliative patients during bullet rounds and conversation s - Complete CCAC Palliative Care Referral Form, give to Unit Clerk Primary Nurse Unit Clerk Physician Hospital CCAC Products Identify eligible palliative patients during bullet rounds and conversation s Discuss referral option and ACP with patient Obtain consent for referral Complete discharge planning checklist, give to Unit Clerk N / A N / A Fax completed Discharge Planning Checklist to hospital CCAC Provide insight on prognostication (< 12months to live) (or NP): Discuss referral option and ACP with patient Fax completed CCAC Palliative Referral form to hospital CCAC (or APN): Contact MRP in community N / A N / A Endorse referral Review OHIP validity, services requested, resident of MH LHIN Palliative Referral Poster Letter for patients & families ACP Toolkit Resource Guide Discharge Planning Checklist CCAC Palliative Referral Form

Community Process Summary VERSION: JULY 30, 2010 Discharge from Hospital First Visit by Primary Nurse Routine Care 1 2 3 a. Completed discharge planning checklist faxed to CCAC a.

18 Community Process Summary VERSION: JULY 30, 2010 Discharge from Hospital First Visit by Primary Nurse Routine Care a. Completed discharge planning checklist faxed to CCAC a. Nurse introduced as primary point of contact for client and family a. PSW observes and reports any issues to their supervisor Description b. Most responsible physician in the community identified and contacted c. Referrals / prescriptions for symptom management kit, CCAC, home oxygen completed d. Client referred to CCAC for palliative service e. Discharge and transportation home arranged by hospital staff b. Nurse completes additional information on Contact Sheet, faxes back to CCAC CM c. Contact for primary care team provided to client and family d. First visit checklist completed and faxed to CCAC (as part of standard reporting tool) e. Problem Identification Tool reviewed, completed as necessary, and included in patient care record b. Nurse completes ESAS and PPS at every visit c. Nurse reviews Problem Identification Tool at every visit d. CCAC CM updates and recirculates Contact Sheet as necessary f. Any problems communicated to Nurse s supervisor, included in verbal report to CCAC CM Products Involved Discharge planning checklist CCAC palliative referral form Problem Identification Tool Contact Sheet First Visit Checklist Problem Identification Tool Contact Sheet

19 Measurement and Evaluation (Indicators) Referrals to CCAC for palliative care ER visits by CCAC palliative clients CCAC palliative clients admitted to hospital Days in acute care Palliative care patients discharged home or ALC Deaths in hospital Family satisfaction

20 400 Inpatient Discharges with Palliative as MRDx, Type 1 or Type 2 in the MH LHIN by Quarter, 2006 to (3286) CREDIT VALLEY HOSPITAL (THE) Number of Discharges (3917) TRILLIUM HEALTH CENTRE- MISSISSAUGA (3926) HALTON HEALTHCARE SERVICES CORP-OAKVILLE (4022) HALTON HEALTHCARE SERVICES CORP-MILTON (4622) HALTON HEALTHCARE SERVICES CORP-GEORGETO GRAND TOTAL 50 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Source: CIHI DAD, Inpatient Diagnosis & External Cause, filtered for Diagnosis Types MRDx, Type 1 & Type 2 with ICD10 Code Z515.

21 90% Palliative Inpatient Discharges in the MH LHIN by Fiscal Quarter , Showing Discharge Status 80% 70% DECEASED Percent 60% 50% 40% 30% 20% DISCHARGED TO HOME WITH NO SUPPORT SERVICES DISCHARGED TO HOME WITH SUPPORT SERVICES (HOME CARE, SUPPORTIVE HOUSING, RETIREMENT HOMES) TRANSFERRED TO CONTINUING CARE FACILITY (INCL. MENTAL HEALTH, REHAB, NURSING HOME, CHRONIC CARE, ETC) OTHER 10% 0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Source: CIHI DAD, Inpatient Diagnosis & External Cause, filtered for Diagnosis Types MRDx, Type 1 & Type 2 with ICD10 Code Z515. Note: Discharge of Other includes: LEFT AGAINST MEDICAL ADVICE (WITH/WITHOUT SIGNOUT, AWOL); TRANSFERRED TO AN ACUTE INPATIENT FACILITY (ACUTE CARE TREATMENT HOSPITAL ONLY); and TRANSFERRED TO OTHER TYPE OF FACILITY (INCL. AMBULATORY CARE, CORRECTIONAL CENTRE, CHILDREN'S AID SOC., ETC)

22 Advanced Care Planning Define key elements of advanced care planning Develop/enhance advanced care planning materials Implement an advanced care planning strategy

23 Resource Guide/Education/Communication Establish a single resource guide for the MH LHIN Develop an education plan for care providers Develop a communication/marketing strategy for the program

24 Portal Development Development of means to share information electronically REACH (Regional Hospitals) CHRIS (CCAC) Development of means to communicate electronically

26 Patient Name: Address: HCN: DOB: Phone: LABEL Gender: PALLIATIVE CARE SERVICES REFERRAL Patient must have prognosis of less than 12 months Patient must agree to receive palliative services Other Contact Name/Phone: Diagnosis: Allergies: Prognosis: (mandatory) 0-1 month <3 months < 6 months < 12 months PPS: (mandatory) % Medical/Treatment Orders: MD/NP Name: Signature: Date: Billing Code: Y / N Request Symptom Management Kit Recommended if PPS 40% and/or at risk for sudden onset of symptoms Y / N Resuscitation status discussed with patient Y / N Patient DNR Referred By (print): Designation: Phone: Date: Referring Physician/NP is responsible for ensuring medical care/supervision is available in community MRP in Community: Day phone: After hours/weekends: (MRP must be aware of and agree to accept responsibility for patient care in community)

27 THE ADVANCED PRACTICE NURSE ROLE

28 APN Role Supports Primary Care Team Referral from any team member May provide hands-on consultative care where the patient is Assessment findings and care recommendations are communicated with primary care team Family doctor remains MRP Community providers supported in their care plan by APN and Pain and Symptom Consultants

29 Referral Criteria Process being created now Complex patient/family needs: what is complex? Symptom management Communication/advance care planning needs No family doctor Limited or novice primary care team in palliative issues

30 Nature of consult Patient care issues System navigation issues Just-in-time consultation (telephone or in person)

31 APN Primary Function To reduce the reliance on hospitals by enabling individuals to die at home through: Reduction of unnecessary ER visits Enabling timely discharge to home with adequate supports Enhancing expert palliative resources available to family health teams One of many strategies to address: Gaps in care from hospital to community Orphaned patients in the palliative phase of illness

32 APN competencies Clinical Not a 100% clinical roll Not physician replacement Full scope of practice through Canadian Nurses Association 2008 Model 4 domains of practice Clinical Leadership Consultation and Collaboration Research Advance Nursing Practice: A National Framework, 2008

33 ENGAGING FAMILY PHYSICIANS

34 Key issues Engagement and integration More than just a course Need for a strategy targeting physician groups Access Content knowledge Operational knowledge Providing active support

35 Supporting Family Physicians Regional On-call Palliative Care MD Advice re: symptom management, decision-making, accessing resources Not a commitment to clinical consultation or access to hospital beds Access for Family MDs and regional APNs Needs Centralized access Review with CPSO/CMPA

36 The future Establishing the current project as a permanent regional program

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