1. MOA role in End of Life Care
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MOA role in End of Life Care
(30 minutes)

2. Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
Grants/Research Support: PharmaCorp ABC
Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
Consulting Fees: MedX Group Inc.
Other: Employee of XYZ Hospital Group
Please fill out all applicable areas (highlighted in red). One slide per speaker.

3. Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
[Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
[Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
Please fill out all applicable areas (highlighted in red).

4. Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to the College of Family Physicians of Canada’s “Quick Tips” document.
Please fill out all applicable areas (highlighted in red).
Please visit the following link for the CFPC’s “Quick Tips” document:

5. 欢迎
We have come together to identify what your role can be in supporting your doctor to try out the things that you all have learned.
Some of you are familiar with the Practice support learning module. Others, who may not have participated in the past will learn that a doctor is not the only one that is involved in the care of his/her patients but he is part of a care team which includes you.
So today we will identify the key points, some of which you are already doing without realizing and some that may be new to you but will someday be common practice in your offices. What we are hoping to achieve is show you what is required to support a patient’s care till the end of their life and what role you can play in making that care more seamless. First we’d like to go around the room to see who everyone is, just tell us your name and who you work for, whether it’s a Solo GP or a group practice

6. Introductions
Introduce yourself and, in a couple of words, your role working with your GP in End of Life Care during the action period.
Example: “Created a registry.”
Introduction
Take minutes to ask each participant to introduce themselves and briefly what they have done during the action period.

7. Identification Gut feeling Things you are noticing
Suggest expand role of MOA identification to include flagging patients by using their gut feeling, thinks you are noticing e.g. gait. Refer to information shared in the first learning session about MOA identification.

8. Assessment
Recognize the impact that these tools may have as patients reflect on their situation while they are completing the tools. They need privacy.
Engaging the family and community to better assess the patient
We want to give you some tips on ways to introduce these tools. Refer to written handouts.
Seniors Assessment Tool
Edmonton Symptom Assessment Scale
Pain and Symptom Diary
Palliative Performance Scale will be completed by the physician.
Assessment tools will have been introduced previously in this session.
You have been introduced to these tools earlier during the assessment section.
The three tools that we can see the MOA assisting with are the Senior Assessment Tool, ESAS & the Pain & Symptom Diary.
In your handouts, there are guides for how you can identify when to introduce these tools and how to assist the patient to complete them.
(Refer to these handouts and review re the use of these tools)
Important before introducing the tool that it makes sense to the pt & family why the tool is being introduced at this time…so relate to their situation (eg James comes to the office with more pain & the physician will do a pain assessment; important to know if he has any other symptoms that need to be assessed as well)
It is also important that you are comfortable having these conversations with pts & families; self-reflection is important for you as well as the physician.
Discussing how you & your physician will use these tools is one of the activities for the action period. If pt is being followed by Home Care, you can let them know that you have provided the pt with a pain & symptom management diary to use.
If there is time, you could role-play how to introduce the ESAS to a patient & family.

9. Seniors Assessment Tool
Screening for distress:
When?
How?
Review questions on the tool; a good way to “normalize” what can be difficult questions as part of this assessment. Some practices find this a good tool to use for annual “check-ups” and can then be introduced as part of a good, thorough assessment. Can provide good information for the Home & Community Care referral if assistance with activities of daily living required.

10. Edmonton Symptom Assessment Scale
** Refer to the pain and symptom diary and the ESAS MOA scripting sheets

11. Pain and symptom diary
** Refer to the pain and symptom diary and the ESAS MOA scripting sheets

12. Care Management
Care Management spans across the transitions. The care plan template is at the core of tracking the care delivered for the patient.

13. MOA Care Plan Template Who are the primary contact people?
Current contact information of all parties.
Ensuring contact with family
How is the family managing with caregiving?
What can you say? What can’t you say?
** Refer to the pain and symptom diary and the ESAS MOA scripting sheets

14. Care management: Tools for toolkit
My Voice (Advance Care Plan).
End of Life care plan templates.
BC Palliative Care Benefits Program form.
No CPR form.
Employment Insurance Compassionate Care Benefits form.
Notification of Expected Death in Home form.
Death certificate.

15. Engaging with community
<Customize this slide to your community >
Identify resources available in the community and how to contact them
Home and Community Care - professional team and HSW.
Specialized palliative care services.
Community supports: hospice societies, caregiver support services, transport, meals, etc.
Create an information package for patients and families
Work with community providers to develop a kit for patients …identify written materials and on-line sites.
Where are additional resources found: local libraries, resource centers.
RSTs are asked to create a package in advance.
We are hoping that the PSP roll-out will include information for the physicians and the MOAs about local community providers…Home & Community Care, palliative care teams, and other community supports; This may be web-based through resources such as CHARD as well as written materials (pamphlets etc).
We need to think about the best way to organize obtaining that information; depending on your role, we have different questions:
-PSP teams: How can the HA PSP team work with each HA to develop a local resource kit for each “roll-out”?
-HAs—What resources do you have that would be helpful to share with the physician’s offices?
-MOAs—what is the best way to organize these resources, both web-based & written, for easy access? 15

16. Office methodology Huddles, pertaining to overall plan
Patient specific huddles
Processes
Billing

17. Office methodology: Things to ponder…..
When will your meetings be?
Who fits “The Surprise Question”?
What will your registry look like?
Where will your toolkit be kept?
What else can you add to your toolkit?
What supports do you need?
What other tools will help you?
What’s in your community?
What is your billing process?
Your comfort level, how do you feel about this?
We have bombarded you with a lot of information and don’t expect that you will have all the answers as to how you can support your doctor with this Module. But what we have done is given you a chance to think about the processes in your office that work successfully and how you can use the success of those processes to figure out how this can fit into your work. You are probably already feeling like the lady in the picture, lots to do and not enough hands. You can also look at this picture differently and see a person who has all her bases covered and can multi task to a perfect art which is something that you are familiar with.
Your role can be what you make it….. Depending on what the plan is with your doctor…..
It starts with planning, getting together and having a conversation, looking at what you are already doing without even realizing it with regards to identifying/flagging and having materials ready that the doctor needs, booking the necessary appointments for the patient and with the family, accessing the resources that your doctor, the patient or the family needs etc.
Your involvement in the planning is crucial…. We talked about how patients can be identified… but what about Registries- how will you keep track of the patients?......
…. We’ve provided you with a toolkit of Materials and supporting documents, what can you add to the toolkit that are community specific and patient specific…..
….. We have talked about what materials will be needed at what level of the care trajectory…. And now the office approach…… looking at what you are already doing vs what changes that you may need to make….. what system are you going to have in your office to manage all of the above and deal with the patient and family needs….
…. The last bullet is your comfort level…. How do you feel about your potential involvement in the end of a patient’s life as a bigger role than faxing a death certificate to a funeral home. It’s not easy to watch someone that you possibly have a relationship with on some level come to the end of their life. How do you remain detached?
These are definite things to ponder….
This section leads us into the next section on the office approach.