1. Joan Doran, Program Lead 27 April 2011 Overview of HPC Teams Education Project Working Together to Support Best Practices in Palliative Pain & Symptom Management for LTC Residents

2. Objectives 1. Update re HPC Teams 2. Overview of capacity building projects  Education for LTC Homes & Community Primary Providers  Physician survey  Physician liaison with HPC Teams 3. Input re Education Project

3. Program Background Partnership: Central CCAC Temmy Latner Centre Southlake Regional Health Centre Funding: Aging at Home, Central LHIN PPSM MOHLTC: Mandate

4. Program Mandate Assists primary providers in application of the Model to Guide HPC assessment tools & best practice Offers consultation to primary providers about palliative assessment, pain and symptom management  In person,  By telephone, teleconference, or  Through e-mail (MOHLTC, 2006)

5. Program Mandate Case-based education & mentoring for primary providers Capacity building amongst front-line service providers re delivery of palliative care Links providers with specialized hospice palliative care resources (MOHLTC, 2006)

6. Regional Cancer Centre's Residential Hospices Hospital PCU's LTC Homes Respite Care Retirement Homes Community Supports Faith Groups Friends Community Organizations Palliative Care Physician Mental Health Consultant CNC Team Visiting / Family Physician Primary Nurse CCAC Case Manager PSW Allied Health (PT, OT, SLP, DT) Social Worker Pharmacist Laboratory Hospice Spiritual Support Patient / Family COMMUNICATIONCOMMUNICATION HPC Teams for Central LHIN Model for Hospice Palliative Care Tertiary / Residential Team Informal Team Expert Team Core Team

7. Advisory Council Dr. Nancy Merrow Dr. Larry Librach Dr. Russell Goldman Evelyn Rosen Joan Doran Anne Grant

8. Clinical Nurse Consultants CNCAreas Christine Alguire Alliston, Bradford, Beeton, King, Maple, Schomberg, Tottenham & Vaughan Mamdouh RezkRichmond Hill & Thornhill Margaret CutraraMarkham & Stouffville Juliana Howes Aurora, East Gwillimbury, Georgina, Newmarket Carolyn WillsonNorth York

9. HPC Program Criteria Patients with a progressive, life threatening illness &/or facing end of life issues Primary intent of treatment is palliative whether palliation of disease, palliation of symptoms (physical, psychological, social) Patient & family agree to referral or to consultative support DNR/No Code status is not required for entry onto the program Unmet symptom management needs of all types

10. Role of the CNC Supporting health care professionals - not replacing the primary providers Professional consultation re PP&SM in the community & LTC Capacity building targeting the knowledge & provision of palliative care

11. CNC Role Facilitation & education at Interprofessional Rounds Networking with health care teams within each geographical region Leadership in standardizing palliative care practice: EDITH, SRK, In-Home Chart Educational initiatives in Central LHIN

12. CCO Toolbox  Common Tools  Isaac  Collaborative Care Plans  Symptom Management Guidelines

14. Referral Process Majority of HPCT referrals from CCAC Community nurses or physicians refer directly: telephone or email Nursing agency or LTC can request a CNC for one or more of their staff

15. Referral Process (cont’d) HPC Teams will admit, reassess immediate needs & contact providers CNC provides consultation report for the physician, CCAC CM, Primary Professional CNC follows the client case with the professional

16. REPORTS ON ACTIVITY Referrals and caseloads increasing as awareness of program grows Each contact with a primary provider to provide recommendations re care plan and pain & symptom management

17. Home Visits Home Visits represent in- home consultation with Health Care Professional ER Avoidance ER visits documented by CNC, Visiting Nurse and CCAC ER ‘visits avoided’ entered into HPC database when CNC consultation prevents patient going to ER for PP&SM

18. Deaths Place of Preference Collect data on place of death and % who die in place of choice For patients who identified a place of preference for death in their plan, October 2010– March 2011 85% achieved their goal

19. Program Hours Core hours, 0830-1630 Mon-Fri After hours on-call available CNCs provide consultation for all health care professionals After Hours Phone: 905-954-5220

20. Contacting HPC Teams Catherine Bazowsky, Administrative Assistant Phone:(905) 895-4521, ext. 6388 Fax:(905) 830-5978 Email:HPCTeams@Southlakeregional.org Website: http://centralhpcnetwork.ca/hpc/hpcteams.html

21. LTC Home Education Project Funded by Central LHIN Provide support to LTC homes in the provision of quality end-of-life care Increase knowledge transfer for the health care team

22. Outcomes Reduction in ER visits Enhanced Pain and Symptom Management Enhanced communication with residents/families Increase utilization of Advance Care Planning

23. Process Requested Expression of Interest Interviewed & selected 4 LTC homes  Representation across LHIN  Gap analysis Collaborated with NLOT Developing curriculum  Physician & RN/RPN  PSW

24. Process (cont) 4 Sessions On-line Repository of Resources Case finding among current residents and case-based mentoring Program evaluation

25. Topics Issues and Challenges in Providing Quality End-of-Life Care Advance Care Planning Working with Families Pain Management and Last Hours

26. Education Hired researcher/education assistant MD/RN/RPN sessions facilitated by palliative care physicians, PC experts, with support from CNC’s PSW sessions will be led by PalCare

27. Evaluation Conduct gap analysis to determine reasons for ER transfers  Chart reviews  Interviews with MD’s, RN, Administration Based on gap analysis, develop, implement and evaluate intervention for quality EOL care

28. Feedback?? What issues do you identify in providing high quality EOL care to LTC residents? Are palliative patients being sent to ER? Why? What needs to be in place to support LTC residents to die in their home?

29. Physician Survey ‘Assessment of Service Provision and Willingness to Engage’ Developed by Dr Russell Goldman and Dr Camilla Zimmerman – TLCPC/ PMH

30. Purpose To determine the level of GP/FP care being provided to community homebound patients

31. Purpose To identify the proportion of physicians who provide the following services to homebound palliative patients:  Scheduled home visits  After-hours home visits  Urgent home visits during office hours  24/7 coverage with after-hours home visits as required

32. Purpose To determine what supports would facilitate PCP’s to engage in the care of homebound palliative patients Develop a registry of PCP’s who would be willing to assume care of patients who do not have access to a FP

33. Methodology Survey all FP who have a primary practice address in Central LHIN Mail out survey/ E mail – (OCFP assisting) Can complete on-line or mail in survey

34. Outcomes Identify barriers to the provision of home palliative care by FP’s Inform the design of an intervention to improve FP capacity and willingness to provide home based palliative care

35. Outcomes Develop a list of FP’s who are willing to take on additional palliative patients Results will be presented at national and international conferences and published in peer- reviewed journals Timeline – to be completed within next 6 months

36. Physician Liaison Physician roster established to provide 24/7 availability Provide support to the HCP Teams CNC’s & FP’s to care for patients in community

37. Questions 37