Palliative Care Community Teams: Supporting a Central East LHIN Model of Care June 2016

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1 Palliative Care Community Teams: Supporting a Central East LHIN Model of Care June 2016 Introduction The Ministry of Health and Long Term Care s (MOHLTC) Patients First: Action Plan for Health Care exemplifies the commitment to putting the needs of people and patients at the centre of our health care system. One of the Action Plan s four pillars is to deliver better coordinated and integrated care in the community, closer to home. As part of the Central East LHIN Integrated Health Service Plan (IHSP), the LHIN set an overarching goal of Living Healthier at Home Advancing integrated systems of care to help Central East LHIN residents live healthier at home. To support this goal the LHIN set a Strategic Aim to continue to support palliative patients to die at home by choice and spend 15,000 fewer days in hospital by increasing the number of people discharged home with support by 17% by To further develop integrated systems of care and support the Palliative Care Strategic Aim the Central East LHIN has committed to implementing Palliative Care Community Teams (PCCT) across the LHIN. PCCTs require health service providers to work collaboratively across Health Link geographies in the development and implementation of interdisciplinary team-based models providing clinical and non-clinical community-based care to palliative and end-of-life patients and their caregivers. Background Palliative Care Community Team (PCCT) Phase 1 Call for Proposals Process In December 2014, the Central East LHIN Board of Directors approved funding to support the development of three PCCTs. The intention was to evaluate, identify lessons learned and support future team expansion to cover all sub- LHIN Health Link geographies in the LHIN. A call for proposals was issued across the Central East LHIN and upon review and evaluation of submitted proposals, three teams were selected to receive Phase 1 funding. Phase 1 PCCTs are situated in the following Health Link geographies and supported by identified host agencies and PCCT partners: Health Link Geographies PCCT Host Agency PCCT Partners Scarborough North / Scarborough South Scarborough Centre for Healthy Communities (SCHC) The Scarborough Hospital, Rouge Valley Health System, Providence Healthcare, Yee Hong Centre for Geriatric Care, East GTA FHT, Carefirst, CCAC, Palliative Pain and Symptom Management Consultant (PPSMC)

2 Haliburton County and City of Kawartha Lakes Community Care City of Kawartha Lakes (CCCKL) Haliburton Highlands Health Services (HHHS) Ross Memorial Hospital, City of Kawartha Lakes FHT, Kawartha North FHT, CCAC, PPSMC Haliburton Highlands FHT, CCAC, PPSMC Other interested providers began or continued dialogue with the LHIN in an effort to prepare for an expected Phase 2 call for proposals. Phase 2 PCCT expansion incorporates three additional teams in the following Health Link geographies with named host agencies to be confirmed (TBC): Health Link Geography Peterborough City and County Northumberland County Durham North East / Durham West To be confirmed To be confirmed To be confirmed PCCT Host Agency PCCT Quality Improvement Planning Day To build on successes and improve on lessons learned from the original three teams, the LHIN organized a two day Quality Improvement Planning event in February The event was hosted by the Central East LHIN, supported by Health Quality Ontario (HQO) and attended by over 80 hospice palliative care and end of life stakeholders from across the LHIN. The intent was for communities to come together to share and discuss lessons learned and build on best practices, all within regional and provincial contexts. Discussions were designed to lead to a level of standardization across teams and sub-lhin Health Link geographies in terms of: A shared understanding of the how PCCTs will function across the region and at the system level. Developing one standardized model of care that all teams would work to implement across the region. Approach Drawing on Lean principals and Quality Improvement approaches, value stream and flow mapping exercises were used to develop a shared understanding of current programs and service offerings in the palliative care system, across the patient continuum of care. Current models of care being used across PCCTs were captured, allowing for analysis and discussions about potential improvements and opportunities for change. Through these approaches, clients, caregivers, providers and other stakeholders co-designed a desired future state that removed waste and increases value for the target population. Emerging Themes & Discussion Highlights Within breakout groups and larger group discussions, a number of strategies and approaches emerged based on highlighted lessons learned from existing PCCTs and emerging planning tables. The following themes/key elements of success were identified: Building strong relationships and partnerships at the organization and provider levels is an enabler of role clarity and creates the foundation for ongoing collaboration. Expanding PCCT target population and scope to enable improved patient/family/caregiver care and experience, and decreased risk of service duplication across the continuum of care. 2

3 Support role of PCCT and PCCT Registered Nurse (RN) Navigator position as point of contact for patients/families and caregivers across the continuum of care. Providing 24/7 access to care to support improved outcomes for patients, families, caregivers and the health system. Palliative Care Community Team Model and Expectations The PCCT Model is intended to enhance existing interdisciplinary expertise through a collaborative approach that focuses on opportunities to create a broader, comprehensive, seamless service delivery model. The PCCT and providers within the Circle of Care are expected to provide a holistic palliative care approach including disease management, physical, psychological, social, spiritual, practical, end-of-life, and bereavement support. The PCCT should include a Palliative Navigator, Supportive Care Counsellor, Administrative Support, CECCAC Palliative Care Coordinator (when eligible), and CECCAC Palliative Care Nurse Practitioner (when eligible). The PCCT is a strong advocate for the patients and caregivers and will navigate them through health and community services frequently required at diagnosis through to end of life and bereavement. The PCCT will provide continuity of care for patients and caregivers from diagnosis to bereavement. The PCCT will support integrated systems of care by partnering closely with providers in the Circle of Care including (but not limited to): Primary Care Specialty Care CECCAC Contracted Service Providers Hospice Community Support Services Hospital Health service providers in the Circle of Care are expected to work collaboratively incorporating and utilizing existing resources and services in their community to create integrated systems of care. See Figure 1 for model depiction. 3

4 Figure 1. Integrated Central East LHIN Palliative Care Delivery Model 4

5 PCCT Future State Based on the February 2016 Quality Improvement Planning event, the following PCCT future state was developed: Referral and Intake Assessment Care Planning Care Delivery Death Bereavement The PCCT future state has been embedded within the Integrated Central East LHIN Palliative Care Delivery Model (Figure 1). Referral and Intake: PCCTs are to provide point of contact for referrals o PCCT centralized phone number o Information on host agency website Use of common Referral Form and common Intake Form A pathway for 24/7 and urgent care, and establish a 48 hour turnaround time once a referral is received Referrals may be received from multiple access points including hospitals, community, primary care, CCAC, Long-Term Care Homes, caregivers, self-referral, other Assessment: Joint assessment with multiple health care providers where possible/necessary Use of common Assessment Form Care Planning: Use of common Consent Form Coordinated Care Conference should be coordinated by PCCT supporting involvement from Circle of Care representatives, patients and caregivers Appropriate patients are supported with a Health Link Coordinated Care Plan (CCP) Ongoing collaboration and communication via rounds and CCP Care Delivery: Health Link CCP used to document and communicate changes to care plan Death: Knowledge, training and use of CCAC s Expected Death Package, as appropriate Standardized processes and follow-up for death i.e. death is communicated and documented with Circle of Care and CCP Bereavement: Direct service through PCCT or referral to bereavement services

6 Target Population During Phase 1, the initial target population for the PCCTs was identified as patients in hospital diagnosed as palliative that could be cared for in the community. Specifically: Patients with a Palliative Performance Scale (PPS) of 40 or less; and Patients with unmanaged pain and symptoms. Based on lessons learned, successes and feedback from existing teams, the PCCT target population has been broadened to include individuals diagnosed with a life limiting illness. Broadening the target population allows for teams to better address aspects of patient care earlier on in palliative trajectory including psycho-social supports, caregiver relief, decreased emergency department visits, decreased hospital admissions, bereavement and education services. Patient eligibility is not limited to a specific clinical grouping. PCCT Scope of Service It is the expectation that the PCCT in partnership with the Circle of Care partners implement a model with common elements and tools. The PCCT and partners within the Circle of Care must work towards: Delivery of clinical and non-clinical hospice palliative care supported by inter-professional protocols and a shared care philosophy. Hospice palliative care for patients and their caregivers includes but is not limited to disease management, physical, psychological, social, spiritual, practical, end-of-life, and bereavement support. Ability to support a seamless transition for palliative care patients in and out of the hospital. Advance Care Planning with patient and caregiver(s) in alignment with provincial strategy and direction. Collaboration and facilitation of timely access to primary care support. Provision of support after hospital discharge and rapid response to those at risk of readmission (within hours). Delivery of evening and weekend care (24/7). Ability to monitor and manage urgent and episodic issues that arise. Ability to build knowledge and education within health service providers. Base Funding $350,000 per community Phase 2 PCCT Funding will not be provided to develop a PCCT with all new human resources and funding cannot be used for physician compensation. There is an expectation to utilize existing resources, although through planning, potential gaps may be identified where there is a need for new human resources. Tool and Strategy Standardization The following tools and strategies will be standardized across all PCCTs: PCCT Mission, Vision Values PCCT Referral Form PCCT Intake Form PCCT Assessment Form 6

7 PCCT Consent Form Health Link Coordinated Care Plan Memorandum of Understanding (signed by health service providers in the Circle of Care) Communication Plan & Marketing Strategy PCCT Roles and Responsibilities Minimum Staffing Requirements Position Description Registered Nurse (RN) Navigator with Palliative Expertise* Administrative / Program Assistant* Supportive Care Counsellor* Start-up Project Management (Up to 1 year with option to hire PCCT FTE after implementation)* Other positions based on needs of community Operational Costs Required FTE Qualifications/ Designations *Required position RN with Advanced Practice Certification in palliative care, LEAP, CAPCE College diploma in Medical/Office Administration or related health field + palliative care /bereavement knowledge Masters in SW, Divinity, Theology, Counselling, Psychology or related field. Additional Certification in Thanatology, Grief and Loss, Bereavement or equivalent PM Certified and/or PM/QI experience in palliative care or related health field + palliative care /bereavement knowledge Contribution towards phone, Internet, supplies, licensing, equipment Funding Type Ongoing Ongoing Ongoing Ongoing Ongoing Ongoing Accountability Accountability for the PCCT funding will be to the LHIN. Quarterly reporting to the LHIN based on indicators developed by Central East LHIN and PCCT Community of Practice is required. Health service providers in the Circle of Care will have shared accountability for delivery of service. Provider responsibilities will be embedded in Memorandums of Understanding. Local Steering Committees are to be developed to oversee planning, implementation and monitoring. All funded PCCTs are required to have representation on the PCCT Community of Practice for learning, standardization and shared practices across all Central East LHIN PCCTs. 7