1. Planning for the Action Period (40 minutes) 1

2. Model for Improvement: 3 Fundamental questions Aims Measures Change ideas 22

3. Practice aims: What are we trying to accomplish? 3

4. Module aims To improve the care of patients and families living with, suffering and dying from life-limiting and chronic illnesses by:  Identifying patients early who could benefit from a palliative approach to care  Enhancing GP & Specialist confidence and communication skills to enable Advance Care Planning (ACP) conversations.  Improving the experience of health care providers, patients and families: o Assessing patient and family needs from a palliative perspective. o Improving the experience of the patient, family, physician, MOA and healthcare providers in End of Life care. o Improve physician confidence related to End of Life care (e.g. care planning, forms). 4

5. Module aims To improve the care of patients and families living with, suffering and dying from life-limiting and chronic illnesses by:  Improving collaboration: o Identifying and referring appropriate patients to specialty palliative care and others for consultation and services. o Understanding provider needs, clarifying roles, tools and resources for practice support and collaboration. o Improving collaborative care planning, coordination and communication with patients/caregivers and physicians and other local health care and community providers. “Integration in Action” 55

6. Practice measures: How will you know a change is an improvement? 6

7. Moving forward… with measurement “If it is not measured, it's not medicine.” - Dr. Marshall Dahl “Some is not a number, soon is not a time.” - Dr. Don Berwick “Without data, everyone is perfect.” - Dr. Paul Murray “Data drives improvement.” - Dr. Neil Baker “The pride in which you wallow, without data may be hollow.” - Dr. Dan MacCarthy 77

8. Measurement The purpose of measurement is for learning not judgment 88

9. PSP End of Life Key Measures – Measured by practice # of patients identified and placed on a registry. % of patients on a registry with a collaborative proactive care plan in place. % of patients on patient registry that have been given My Voice and had an ACP conversation. % of patients on the registry that had an ESAS and or PPS (as appropriate). 99

10. Key measures – non-practice based % of GPs and healthcare providers that have an improved experience in caring for patients at End of Life. % of GPs that are confident when engaging patients and their family in conversations about End of Life (1-10 confidence scale). % of patients/caregivers who feel comfortable with their End of Life care plan. % of caregivers who feel supported when caring for patients at End of Life. 10

11. Data Tracker and Narrative Report 11

12. Change Ideas – What changes can you make that will result in improvement? 12

13. Finding changes End of Life change package. Team ideas. Peer changes. 13

14. Example: Registry What is it? A list A database What is it used for? Tracking progress Proactive recall What types are there? Paper list Excel spreadsheet Binder Flagged chart EMR based 14

15. Where to start: What changes can we make that will result in an improvement? What are you going to do next Tuesday? What is the plan? Remember to think about how you will measure/track improvement. Record on Action Plan and report back in 15 min. 15

16. Testing Changes – What will you start when you get home? 16

17. Just try it! Use of Advanced Care Plans Better awareness of patient needs and preferences = Better Death AP SD DATA Cycle 1: Test having a conversation on ACP with 1 patient. How long do the conversations take? Is the patient comfortable? Are you comfortable? Cycle 3: Try ACP conversations with 5 clients, how can you do this at scale? How might you need to plan your visits to accommodate? Cycle 1 Cycle 2 Cycle 3 Cycle 2: Test having an ACP conversation with a different client with different characteristics or at a different place along disease trajectory. Where there differences? Do you need to adjust? AP SD AP SD 17

18. Action period expectations Try tests of change. Measure and track your progress. Regional Support Team (RST) practice visits. Support throughout the action period you can expect: Practice visits from the coordinator. 18