1. Westin Wall Centre Hotel
End of Life
Train the Trainer 1
Westin Wall Centre Hotel
December 9, 2010

2. Pat Porterfield, Josefa Kontogiannis
End of Life MOA role
Pat Porterfield, Josefa Kontogiannis
*A/V tech: these slides to be played in Steveston Ballroom (96 to 110)

3. 欢迎
Hello, My name is Josefa Kontogiannis, I am a Practice Support Leader for Vancouver Coastal Health Authority; This is Pat Porterfield (role) we want to welcome you to this Medical Office Assistant break out session of the Train the trainer session of the End of life Palliative Module. Otherwise known as the (BCMA PSP TTT of the EOL Pal MOA BO session) Module. Your doctor has signed up for this Train the trainer session so that he/she can get the information that you have heard today and try it out in your offices so that eventually he or she can facilitate the module to other GPs in Learning sessions such as these. 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

4. Getting started… what is the palliative approach?
Expanded definition of the End of Life.
Guided by an understanding of the illness progression.
Assists in understanding the transition of illness from cure to symptom control.
Improves quality of life in all life-limiting illnesses.
As you heard today… the Palliative Care approach looks at the expanded definition of the end of a person’s life guided by an understanding of the illness progression and of the transition of illness from cure to symptom control to improve a persons quality of life at the end of their life , so instead of concentrating on a cure, it looks as making a person comfortable because they are palliative. Although the quantity of their life is becoming shorter, the quality should still be respected.
When I look at this approach I think that this is the way I would like to be taken care of when it will be my turn or how I would like my mom to be taken care of. I’m sure that you would agree.

5. End of Life Module: MOA Role
Identification
Flagging
Gut feeling
Surprise Question
Things you are noticing
Care management
Planning
Registry
Tools
“Paperwork”
Assessment
Communication
Tools: ESAS, pain diaries etc.
Engaging family
Engaging community
Office methodology
So…. In your packages you will find a folder that contains all the documents that you will need when a patient is assessed as being palliative-End of life. We have structured the folder in the hopes that it will be ready to use when you need it…..and that all it would need are supporting information that are specific to your office or community. This will be your toolkit
***Note to facilitator, the reason for this wording was because we had wanted a starter kit as part of the MOA package in the form of a two pocket folder; one side containing the assessment tools (ESAS, PPS, Seniors assessment tool) and the other containing the necessary documents that will be required at some stage of care of the patients (care plan template, My voice, No CPR, BC Palliative benefits, compassionate care benefits, notification of expected death at home, death certificate). Something tangible that will hold all these documents together so that all it would need throughout the progression are the office and community specific tool/materials/resources***
Also in your package are possible tools or materials that you may receive throughout the time that the patient is receiving End of Life care. As well as a folder of supporting documents that may also help you
At the top of your package is the sheet entitled “MOA role in Palliative care”…. We will be referring to this sheet as it’s a good guideline to help in our discussion today, specifically with the four headings… Identification, Care Management, Assessment and Office Methodology…
You are definitely key in helping identify patients…. you are seeing them all the time and interacting with them in a different way than even the doctor interacts with them. Many times you may notice something different about a patient or have that gut feeling. Today you learned about the surprise question…. I’m sure it made you start thinking of some patients….. Flagging is the one of the important first steps
Care management comes to play once patients have been identified…..however…it needs some planning. How do you assist in the management of a patient’s care when it comes to end of their life. How do you keep track of patients, what tools do you need and what paper work in necessary…. This is where your toolkit is vital
Assessments are done by physicians but your role in the assessment process started with identification and communications with the patients, their families and with the doctor. You may also be called upon to expedite calls regarding patients that are dying…. You may also be called upon to help patients and families with the paperwork that is required that pertains to assessment
But… a lot of this does not happen without planning how this will work in your office. Huddles or team meetings are important but there are actually two kinds of meetings…… one being an overall planning meeting with respect to the module (this may only happen a few times in the process)…. The other, being patient specific meetings. You will also need to develop processes in your office about… the registry, organization of materials, billing, etc. We are hoping that this toolkit will be especially helpful for you in your offices and will be looking forward to feedback about how it worked for you.
Also in your package is the module implementation planning sheet that can act as a starting point when you go back to your offices. Find time to have a meeting, keeping the criteria on one side of the sheet in mind while using the other side to write down your plan.
Huddles, pertaining to overall plan
Patient specific huddles
Processes
Billing

6. Identification: Surprise question
Would you be surprised if this patient will die within the next year??? This question will be the physician’s “trigger”… how can you help?
What are the signs to look for? What are the questions to ask yourself?
What are the steps to take when you start answering “No” when thinking of certain patients?
Pat talked to this slide
You have been introduced to the surprise question earlier this morning. I would just like to reinforce the intent of using this question:
-for early identification of patients who may be in the last year of their life; we need to be clear that we are not certain & we need to journey with the pt & family to see how the illness will unfold. We need to recognize that at the point we are doing this early identification, the pt & family will often not see themselves in this way; more often they will see themselves as living with a chronic illness; sensitive communication with the health team is key to accompanying pts & families on this journey.
-why to we want to identify patients earlier than what we are doing currently? To be proactive in assessing their needs & providing the appropriate care. If we wait until we are certain that patients are approaching the end of their lives before we assess these needs, we often miss opportunities to help improve their quality of life.

7. Identification - what changes do you see?..... Flagging
Changes in appearance.
Missing appointments.
Admissions to Long Term Care or multiple hospital visits or even frequent doctors visits.
Family members expressing concern, wanting to talk to the doctor about them.
Changes in behaviour.
Changes in gait.
Decrease in ability to care for themselves.
Changes in communication.
Gut feeling.
These are the things that will help you see with the Surprise question…. Are you noticing any of these things when seeing or talking to patients?...
Changes in appearance; where a patient was generally clean shaven or nicely dressed, they are not so much now
Missing appts either with your office or appts that you have booked for them to see a specialist
Admissions, to hospital or even multiple visits to your office…. You seem to be seeing them a lot more lately
Family members calling to talk to the doctor or asking you for information
Behavioural changes, where they were generally polite, they are now short and rude, or confused
Changes in gait; needing more support, now using a walker, walking slower, holding on to the wall, shaky etc
Decreased abilities; forgetting things, needing more assistance than normal
Changes in the way the communicate with you; are you noticing this at all
If so…..Ask the surprise question… then have a conversation with the doctor about them.

8. Registry What types are there? What is it? What is it used for?
A list
A database
What types are there?
Paper list
Excel spreadsheet
Binder
Flagged chart
What is it used for?
Tracking
Maintaining
Follow up
Today you heard mention of a patient registry which is a tracking system of patients with common health concerns. Having these types of registries is a good way of keeping the elements of a health condition in check.
They have been commonly used for chronic conditions such as diabetes or hypertension. With a Registry, at a glance you can make sure blood work is done, that the patient has been seen, meds are up to date etc.
A registry can be kept to manage the care of patients at the end of their life as well possibly in a checklist format or visit by visit format etc. It can also contain important information about the patient regarding family contact information and phone numbers of other specialties or services that the patient is accessing. You have probably started thinking of names of people who fit the Surprise question. Naturally what do you do….. Start a list. A list is a good first step toward creating a registry. It is with this list that you start thinking about the things that you would like to monitor with your End of life patients.
It can be kept in many ways such as a paper list, an excel spread sheet, a binder or a flagged chart or tailored somehow in an EMR for specific identification.
Have a conversation about what you would like your registry to look like, and also discuss how you are going to start picking patients and once you do pick patients, what do you do with the people that you picked?
Talk to your PSP coordinators about ways that they can help you get started and support your implementation of the module

9. Care management: Tools for toolkit
Care plan template.
EOL care MOA flow sheet.
My Voice (Advance Care Plan).
No CPR form.
BC Palliative Care Benefits Program form.
Employment Insurance Compassionate Care Benefits form.
Notification of Expected Death in Home form.
Death certificate.
Describe what is in the toolkit necessary and ready for care management

10. Using the assessment tools:
Palliative Performance Scale (PPS)
ESAS: Screening for Distress
When?
How?
Pain and Symptom Diary
Seniors Assessment Tool
You have been introduced to these tools earlier when Dr. Barwich discussed assessment.
The two tools that we can see the MOA assisting with are the 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.

11. Engaging family 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?
Following patient’s death, contacting family
What family needs to do after death?
Family members that aren’t actual patients, how are they seen or informed?
Discuss your possible roles in making bereavement calls or cards.
Palliative patients have a network of people caring for them, particularly the family members who provide round the clock care alongside many health care professionals.
They are responsible for not just appointments but making decisions throughout the progression of their Loved one’s “end of life” but they are making plans about the death. They are also executing the decisions of all the health care professionals that are responsible for their loved one’s life. They also have their own households and obligations to themselves and other members of their family and need to take care of their own mental health when coming to terms with the fact that their family member is dying. Remember, this time can be very lengthy and they can become exhausted and frustrated.
They will be calling your office for and with information and updates; have a plan in place to manage them when they call, know who they are and have the necessary contact names and phone numbers available. In the long run, this will save you and them some time during the phone call and will also foster a relationship between you and them that will make the calls run more seamlessly.
It’s also important to have a discussion with the doctor about what the family understands is happening to them because you don’t want to say something that they are surprised to hear
Have information about post-death necessities and a system in place regarding how this is delivered to the family members and where this information is kept for easy access (who provides the info, where is it kept). Should it be kept as part of your toolkit?
Also have a process in place around what to do when the patient dies
Are there appointments that need canceling
Where do you send the death certificate
Do you call the family
Do you send a card
Do you set up bereavement appointments, what do those look like, how long should they be
What about family members who need bereavement but are not patients of the doctor, what happens to them? What is done with respect to billing for any member of the patient’s family who is not a patient? These are things that can be taken care of before they become a potential problem.
These are discussions that should take place during a planning meeting.

12. Engaging with 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.
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? 12

13. Websites to obtain important forms
BC Palliative Care Benefits Program application form
Employment Insurance Compassionate Care Benefits
ssionate.pdf
Notification of Expected Death
Here are the websites where you can obtain these forms….. The notification of expected death, the BC Palliative benefits program form and the employment insurance compassionate care benefits form.

14. 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….

15. Thanks and feedback
We would appreciate your contact information so that we can keep in touch with you and further support your implementation of this work.
A listserv has been set up so that we can get feedback to see how you are doing throughout the process.