Creating Compassion with Palliative Care: A A Provincial - - PowerPoint PPT Presentation

Creating Compassion with Palliative Care: A A Provincial Perspective

• Dr. Ahmed Jakda

March 28, 2018

What is the Ontario Palliative Care Network?

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Drivers for Change in Hospice Palliative Care in Ontario

In October 2014, the former Hospice Palliative Care Provincial Steering Committee identified that the gaps called out in the Declaration, still existed. There was still no formalized provincial network with clear accountability to drive the delivery of quality coordinated hospice palliative care.

Inadequate & inequitable access to integrated, high quality hospice palliative care Inadequate support for caregivers Limited & inequitable service capacity across all care settings Lack of clear accountability for the delivery

• f hospice

palliative care Lack of system integration

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What is the Ontario Palliative Care Network?

An organized partnership of community stakeholders, health service providers and health systems planners responsible for the development of a coordinated, standardized approach to the delivery of hospice palliative care services in Ontario. Shared leadership responsibility Collectively, these partners have the skills, knowledge, resources and reach to provide the leadership, practical knowledge, oversight and governance to deliver on the mandate of the network. Health Quality Ontario Quality Hospice Palliative Care Coalition of Ontario Accountable for the OPCN The LHINs CCO

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The Mandate of the Ontario Palliative Care Network

Our Past, Present & Future Work

Working Towards High Quality Palliative Care in Ontario

High gh qua quality, coor

• rdinated

ed, ho hosp spice pa palliative care e in n On Ontari rio Palliative e Care Qua Quality y Stand ndard (2017 2017-18 18) PA John n Fras raser er Report rt: Five e Pr Priori rities es (201 016) Declaration

• n of Part

rtnersh ship: p: 6 Pr Priori rities es (201 011) Pr Prov

• vinci

cial Perf rform rmance e Sum ummary ry OPCN’s 3-Yea ear Act ction

• n Plan

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OPCN’s Work to date

Since the launc nch h of the e OPCN, we have e accom

• mplish

shed ed the followi wing ng:  Used a data-driven and evidence-based approach to provide recommendations on allocation of new residential hospice beds  Supported the LHINs with regional capacity planning data  Put processes in place to ensure ongoing access to high-strength long-lasting

• pioids for patients requiring these medications for palliative purposes

 Engaged 200+ stakeholders in development of a the OPCN Action Plan and the development of provincial indicators for quality hospice palliative care

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OPCN’s Work Moving Forward: The OPCN Action Plan

The Action Plan guides our work between now and March 2020, it:

• Places patients and their caregivers at the centre
• Supports coordinated system level change through alignment of planning,

implementation, monitoring, and reporting both at and across the regional and provincial levels of focus

• Aligns with the structural changes occurring in Ontario’s health system through

the Patients First initiative

• Addresses the full spectrum of settings in which palliative care services are

delivered (home, community, long-term care, hospice, or hospital) as well as the broad range of geographies in which Ontarians live (north and south; urban, rural, and remote)

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Action Areas for the OPCN Action Plan

• Enhancing Patient and Caregiver Engagement in Palliative Care

A

• Aligning the Planning for Palliative Care Across the Province

B

• Enabling Early Identification of those Who Would Benefit from Palliative Care

C

• Establishing Palliative Models of Care that Enable Adoption of the Quality Standard

D

• Identifying and Connecting Palliative Care Providers

E

• Building Provider Competencies in Palliative Care

F

• Measuring and Reporting on our Progress

G

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OPCN Work Currently Underway:

1. Developing a Palliative Care Quality Standard for Ontarians 2. Developing recommendations on the ideal model of care for patients receiving palliative care services within their last year of life 3. Developing recommendations on the educational requirements for health care providers providing palliative care 4. Supporting early identification of patients who would benefit from palliative care 5. Prioritizing indicators to enable performance measurement and reporting 6. Building stronger understanding of palliative care needs within priority populations (vulnerably housed/homeless, FNIM, pediatrics, Francophone)

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• 1. Developing a Palliative Care Quality Standard
• As a key OPCN Partner, HQO is supporting the development process
• The focus is on palliative care for adults with progressive life-limiting illness.
• The product is a go-to resource containing a set of evidence-based,

measurable statements outlining what high-quality palliative care should look like for patients, caregivers, and health care providers

• OPCN Provincial Clinical Co-Lead co-chairs the Palliative Care Quality Standard

Working Group which has diverse representation across geography, health sectors, lived experience, and health disciplines

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Draft Quality Statements of the Quality Standard

1. People with a progressive, life-limiting illness have their palliative care needs identified early through a comprehensive and holistic assessment. 2. People with identified palliative care needs have access to palliative care support 24 hours a day, 7 days a week. 3. People with a progressive, life-limiting illness know who their future substitute decision-maker

• is. They engage in ongoing communication with their substitute decision-maker about their

wishes, values, and beliefs, so that the substitute decision-maker is empowered to participate in the health care consent process if required. 4. People with identified palliative care needs or their substitute decision-makers have discussions with their interdisciplinary health care team about their goals of care to help inform their health care decisions. These values-based discussions focus on ensuring an accurate understanding of both the illness and treatment options so the person or their substitute decision-maker has the information they need to give or refuse consent to treatment.

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Draft Quality Statements of the Quality Standard

5. People with identified palliative care needs collaborate with their primary care provider and

• ther health care professionals to develop an individualized, person-centred care plan that is

reviewed and updated regularly. 6. People with identified palliative care needs have their pain and other symptoms managed effectively, in a timely manner. 7. People with identified palliative care needs receive timely psychosocial support to address their mental, emotional, social, cultural, and spiritual needs. 8. People with a progressive, life-limiting illness, their future substitute decision-maker, their family, and their caregivers are offered education about palliative care and information about available resources and supports.

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Draft Quality Statements of the Quality Standard

9. Families and caregivers of people with identified palliative care needs are offered ongoing assessment of their needs, and are given access to resources, respite care, and grief and bereavement support, consistent with their preferences. 10. People with identified palliative care needs experience seamless transitions in care that are coordinated effectively between settings and health care providers. 11. People with identified palliative care needs, their substitute decision-maker, their family, and their caregivers have ongoing discussions with their health care professionals about their preferred setting of care and place of death. 12. People with identified palliative care needs receive integrated care from an interdisciplinary team, which includes volunteers. 13. People receive palliative care from health care providers and volunteers who possess the appropriate knowledge and skills to deliver high-quality palliative care.

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• 2. Developing Recommendations on the Ideal Model of Care
• A Health Service Delivery Framework (HSDF) Working Group was established to

describe and recommend a model of care for palliative care that:

• Delivers high quality, culturally relevant care to all of the population in need
• Builds sufficient capacity among community care providers that will sustain the

system over the long term

• Enables the implementation of the HQO Palliative Care Quality Standard
• The first area of focus is adult patients receiving care within the last year of life

and residing at home (e.g. patient’s living in their usual place of residence*).

• As per the Working Group’s advice, HSDF will focus on more than the last year of

life

• Testing the recommended model of care will align with testing of early

identification tools

• The Recommendations will be tested and evaluated to assess the feasibility and

effectiveness of the recommended Models of Care.

*Usual place of residence can include long-term care homes and retirement homes

Guiding Principles of the Health Services Delivery Framework

• Centre around the needs and preferences of individual patients and their

caregivers

• Respect and account for the important roles (and availability, willingness, skills

and abilities) of family members and other caregivers outside the formal health care system

• Enable equitable, high quality care as close to home as possible
• Ensure that interdisciplinary team members have the necessary competencies

and work to the full scope of their practice

• Ensure that capacity building is embedded within the framework to ensure a

sustainable system of care for the future.

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Approach to Understanding the Needs of Patients

Figure 1: Adapted from Advancing High Quality, High Value Palliative Care In Ontario: A Declaration of Partnership and Commitment to Action and Pallium Canada

The delivery of care is guided by the needs of patients, families and

• caregivers. It has long been recognized

that those needs vary in complexity

• ver the trajectory of illness.

Rather than defining distinct subpopulations, the HSDF Working Group recognized that the framework needs to be flexible enough to respond to those needs as they change over time

HSDF: Core Elements

• Early Identification, Assessment and Coordination
• Palliative Care Teams
• Care Planning
• Delivery of Care
• Support for Family and Caregivers
• Palliative Care for FNIM

Draft 2.0 Recommendations for a Model of Care to Improve Palliative Care*

Key Concepts:

• Patients with palliative care needs and

their family/caregivers should have 24/7 access to a core primary level team.

• The primary level team will have 24/7

access to the specialist team for medical issues and support.

• Specialist teams are involved on an ‘as

needed’ basis.

• MRP will ideally be the patient’s family

physician.

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• 3. Developing Education Recommendations
• The OPCN has established a Provincial Palliative Care Education Steering

Committee, that will develop:

• Recommendations for required competencies for health care providers delivering

palliative care.

• A provincial inventory of existing educational programs.
• Recommendations for continuing education programs that meet the criteria

required to develop the appropriate palliative care competencies.

• A plan to embed the palliative care competencies education into undergraduate

curricula for providers.

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• 4. Support Early Identification
• Identifying patients who would benefit from a palliative approach to care, in a

timely manner, is key to transforming palliative care in Ontario.

• There are two distinct streams of work, that focus on:
• Developing a cohort of people

identified with palliative care needs using administrative data assets Administrative Data

• Exploring evidence based

algorithms/tools to support clinicians with identifying patients for further assessment and referral Clinical Implementation

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• 5. Prioritizing System Level Measures
• The OPCN is currently developing a Provincial Performance Summary that will

allow healthcare system leaders and stakeholders to evaluate overall performance and progress against the Action Plan.

• Reporting is anticipated to commence in the next fiscal year.
• The summary report will include:
• Four system level indicators to measure progress on the goals of the Action Plan
• A series of small dot indicators to provide additional insights and detail in support
• f the system level measures and actions

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Four System Level Measures

% of decedents who died in hospital*

* Other locations of death will continue be reported, but are not system level measures

1

% of community dwelling decedents who received physician home visit(s) and/or palliative home care in the last 90 days of life

2

% of decedents who had a) 1 or more ED visits or b) 2 or more ED visits in the last 30 days

• f life

3

% of caregivers of decedents who received palliative care services who were invited to respond to a CaregiverVoice survey

4

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• 6. Understanding Needs within Priority Populations
• Enhance engagement and representation in governance structure with priority

populations

• This

s year ar we are: e:

• Establishing a dedicated First Nations, Inuit, and Métis engagement plan
• Bringing together a Knowledge Sharing Forum to support regional projects focused
• n homeless/vulnerably housed and consider opportunities to scale and spread

across the province

• Nex

Next year ar we wi will:

• Continue engagement with key pediatric palliative care stakeholders and plan for

Palliative Care Quality Standards for Pediatric population

What are the Levels of Palliative Care?

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Primary Level Palliative Care: A Palliative Approach to Care

Illness trajectory Diagnosis Death

Patient C Patient F Patient D Patient E

• Most individuals require only primary-level

Palliative Care (A Palliative Approach to Care)

Patient B Patient A

COMMUNITY

Primary Care Clinicians (i.e. Family Physicians, Nurse Practitioners, Family Health Teams, Nurse Practitioner Led Clinics, Community Nurses, Home Health Care Providers, Pain and Symptom Management Consultation Teams, Emergency Care, etc.) Non Specialist Clinicians (i.e. Oncologists, Internists, Geriatricians, Pediatricians, Respirologists, Cardiologists, Neurologists, Critical Care Physicians, Surgeons, etc.)

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Primary Level Palliative Care –Role, Providers, and Settings

Role Examples of Health Care Professionals Examples of Settings

• Occasionally see patients with life

threatening and life limiting illnesses

• Focus of work is on initiating a palliative

approach to care

• Refers to secondary and tertiary level

palliative care expertise when issues are complex and requires specialist level assistance

• Much of palliative can be effectively

provided at this level

• Family physicians
• Primary care nurses and RPNS

hospitalists

• Specialists and nurses in any

specialty area that has contact with patients with life threatening illnesses (e.g. internal medicine, surgery, pediatrics, geriatrics, etc.)

• PSWs
• Community (family

medicine clinics, LTC homes, retirement homes)

• Hospital units
• Outpatient clinics
• Emergency

departments

• Hospices

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General Palliative Care

Illness trajectory Diagnosis Death

Patient C Patient F Patient D Patient E

• May occasionally require assistance of a specialized

palliative inter-professional team

• Consultation or shared care support

Patient B Patient A

COMMUNITY

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General Palliative Care –Role, Providers, and Settings

Role Examples of Health Care Professionals Examples of Settings

• See a large number of patients

with life threatening and life limiting illnesses, and a large number of patients requiring EOL care

• Should be able to initiate and

provide a Palliative Approach to Care

• Refers to secondary and tertiary

level palliative care expertise when issues are complex and requires specialist level assistance (through consultation

• r shared care)
• Oncologists and oncology RNs
• Psychosocial oncology
• Allied health professionals
• Cardiologists and internists

(working with large # of patients w/ end-stage organ disease)

• Critical care specialists
• Neurologists (patients with

progressive illnesses)

• Family physicians in hospices
• Retirement homes or CCC
• CCAC Case Managers
• MDs, RNs, and other allied

health professionals

• Cancer Centers
• Critical Care Units
• Neurodegenerative Clinics
• Hospices
• Hospital units
• Home
• Clinics for patients with end stage
• rgan diseases (e.g. heart failure,

COPD, ALS clinics)

• Transplant Units

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Specialist Palliative Care

Illness trajectory Diagnosis Death

Patient C Patient F Patient D Patient E

• A small number of individuals with complex needs

require transfer of care to specialist palliative care services

Patient B Patient A

COMMUNITY

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Specialist Palliative Care –Role, Providers, and Settings

Role Examples of Health Care Professionals Examples of Settings

• Majority of practice is

providing hospice palliative care

• Provides hospice palliative care

clinical consultation, shared care support, and education/coaching to health professionals at “Primary” and “Primary Enhanced” levels

• Addresses needs of patients

with complex needs

• Palliative Care physicians with

the appropriate specialist-level training – Palliative Care Nurse, Practitioners (NP) or Advanced Practice Nurses (APN)

• Medical and Nurse directors of

Palliative Care Units or Hospices

• Palliative Care consultation

teams in hospitals and community

• Palliative Care Units
• Hospices

What is the Role for Primary Care Providers?

• Leads to better outcomes for Patients & Families:

 Reduced symptom burden  Less anxiety and depression  Less caregiver burden  Better quality of life  Less aggressive treatments  More appropriate referral to and use of hospice  Lower health care costs

The Benefits of Earlier & Integrated Palliative Care

What Does Primary Level Palliative Care Include?

• Introduce Advance Care Planning
• Early identification of palliative care needs
• Assessment & Management
• Pain, Symptoms, Depression & Anxiety
• Social & Spiritual needs
• Engage in Goals of Care Discussions and Obtain Informed Consent for Treatment
• Supportive counseling
• Prepare for emergencies

Identifying and Assessing Palliative Care Needs

Questions?

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