GENERAL DESCRIPTION OF MODELS OF SERVICE
Regional Cancer Centres Background and Context
Cancer patients comprise between 80% and 85% of any palliative care team workload.
Cancer Care Ontario (CCO) is the provincial agency that steers and coordinates
Ontario’s Cancer Services and prevention efforts. The Regional Cancer programs have defined accountability to CCO as well as to their host hospitals.
Regional Cancer programs have a unique set of integration accountabilities and
responsibilities in addition to direct responsibility for care provision. Accountabilities and responsibilities include:
• Accountability for oversight and performance outcomes of the regional (LHIN – wide) cancer system, including aspects of palliative care related to cancer service
provision.
• Accountability and shared responsibility for:
o the Integrated Cancer Program at their host hospital (including inpatient oncology unit),
o Satellite clinics off site
• Responsibility for the ambulatory services at the Cancer Centre site including Radiation and Systemic Oncology, Supportive Care etc.
Regional Cancer programs (RCP) have been instrumental in advancing palliative care across Ontario. Cancer Care Ontario has launched a multi-year strategy to improve palliative care. One of the first initiatives of this strategy was the Provincial Palliative Care Integration Project (renamed the Ontario Cancer Symptom Management Collaborative) which articulates aims related to the use of standardized tools and approaches to care. Benchmarked data is available for the outcomes of this Collaborative.
Typical Models of Palliative Care
Clinical Palliative Care services, offered by RCPs across Ontario are evolving. Several RCPs offer outpatient palliative care clinics, several help support consultation services within their host hospital and many have palliative care teams/programs.
Most RCPs have supportive care programs. Supportive care is a term used by RCPs to encompass the work of professionals such as social workers, dieticians, psychologists, and therapists as they physically and emotionally support patients throughout their journey.
Supportive care shares a philosophy of care with palliative care, but has a larger mandate in terms of the full disease trajectory.
Future System – Role of Regional Cancer Programs
The Regional Cancer Programs have a key role in developing and implementing best practice palliative care not only at the Regional Cancer Centres but across the regions and province. (3)
Outpatient Palliative Care Clinics/Consultation Services Background and Context
Clinics are a typical service offered in integrated HPC programs and are seen as an efficient means of providing consultation and follow-up care for community patients who are mobile and well enough to travel.
Typical Models of care
Typically these clinics are staffed by a physician and nurse team, with access to a wider interdisciplinary team. Clinics may be consultation only or consultation and follow-up or consultation and ongoing care (MRP). Clinic sites vary. Often these clinics are located at a Cancer Centre (refer to discussion above) or hospital facility with diagnostic testing and other services on site. Clinics may also be offered in community based settings including residential hospice and community hospice sites.
Future System – Role of Palliative Care Clinics
Outpatient palliative care clinics are an efficient way of providing care to mobile community based patients. Location considerations may include: patient accessibility (including parking), proximity to lab testing, supportive care etc. These clinics will likely become an integral component of a community based expert teams. (3)
Volunteer Visiting Hospice Program (VHP) – Community Support Service (CSS) Funded Service
Background and Context
The Volunteer Hospice Programs were one of the first initiatives funded by the MOHLTC in 1992 and 1993 (funding code was 08D). This program is a Community Support Service (CSS) in which volunteers are recruited, trained and matched with clients. The volunteers are supervised to provide emotional, social and spiritual support to those who are living with a life-threatening or terminal illness and their families.
Volunteers also provide respite and bereavement support.
Typical Models of Palliative Care
These programs have evolved according to the unique demands of the specific locales.
Many of these programs have developed community based day programs in addition to the visiting hospice component. Some regions use their volunteer program across sectors, including community, hospitals, and LTCH. Some are integrated with residential hospice programs where these volunteers may also serve in the residential hospice and in the community day programs in the Hospice building.
Future System – Role of Volunteer Hospice Program in Palliative Care Service Delivery System
It is expected that coordination of volunteer services using innovative approaches (such as maximizing the potential involvement of the patient’s own “circle of caring” (Share the Care™) will continue in order to enhance efficiency of the scarce volunteer resource (3).
It is expected that these volunteer hospice/ visiting hospice programs will be included in expanded outreach program models. (This programs may be the first point of entry to service is sometimes the first accessed or may be the only service available to the client for some time until clinical care needs become more evident and other services are accessed).
The Palliative Pain and Symptom Management Consultation Program (PPSMCP) – Community Support Service (CSS) Funded Service
Background and Model
The Palliative Pain and Symptom Management Consultation Program (PPSMCP) and Education programs were introduced across Ontario by in 1992/1993 (previous funding codes were: 22A, 23A and 24A). New guidelines for service provision were released in 2006 as part of the EOLC strategy. Availability of this service varies across regions. In 2 regions in Ontario all three initiatives are combined under one accountability
mechanism. Several regions have completely separated programs and several regions have combined 2 of the initiatives.
Future System – Role of PPSMCS in Palliative Care service Delivery
It is expected that this program will continue to provide key regional expert level of consultation and education. (3)
Hospice Day Programs (Hospices – non-residential component) – Community Support Service (CSS) Funded Service and Non-Funded Service
Background, Context and Model
In many communities across Ontario, “grass roots movements” have initiated support services for patients requiring palliative care. Frequently these initiatives began as volunteer driven programs determined to fill a much needed gap in care. Typically these initiatives operated as day programs with fundraised and donated dollars. In some cases more permanent funding has been procured – some from MOHLTC, United Way, grants etc. However in many cases fundraising continues to be a key source of operational viability.
Note re definition – Within this context, the term “hospice day programs” is used to distinguish these programs from residential hospice programs. The term does not imply a respite program that lasts a full day – although some programs may in fact serve a respite function. The length of time and objective of each individual day program varies considerably depending on programming capacity and need.
Future System – Role of Hospice Day Programs
Day Programs will increasing be needed to help support patients in the community. (3)
Expert Teams
Background and Context
Expert teams/ consultation teams are a core element of a regional palliative care program and are cited as an essential component of care in every benchmarked regional program (e.g. Fraser Health, Edmonton’s Capital Health, Australia’s model etc.). Ideally these teams operate across sectors. Expert teams are the preferred method of providing “tertiary level / specialist level expertise”.
Frequently a team is what defines a “program” – i.e. patients referred to the team are considered to be “in the program”. There is a significant body of literature to support the development of expert palliative care teams.
CHPCA’s Pan-Canadian Gold Standard for Palliative Home Care lists consultation teams as important for quality palliative care.
Consultation teams typically are multidisciplinary.
Fraser Health lists the following team members:
• Palliative care physician,
• Clinical Nurse Specialist / nurse practitioner,
• Social worker/Counselor,
• Volunteer Coordinator.
• Access to a hospice palliative care clinical pharmacist
Minimally a team would have an MD and RN with access to other professions.
Typical Models of Palliative Care Models of care include:
• consultation only,
• consultation and follow-up,
• consultation and follow-up with direct care provision. (3)
This review underscores the need for HPC expertise in each care setting. It is expected that this expertise will include members of several professions and will constitute the core of HPC service provision in an individual sector as well as connecting between/among sectors.
Future System – Role of Expert teams in the Palliative Care Service Delivery System
Regional expert interprofessional teams, with expertise in sector coordination are viewed as a foundational component of an integrated system of palliative care.
The team will serve as a catalyst for integration and enhanced cross sector cooperation.
Fraser Health describes a “connecting role” for such teams. “The consult teams are a key factor in working towards seamless transitions and care for patients and their families as they move from one sector to another in the healthcare system. They make decisions with patients about the best location of care at a given time in the illness trajectory. Consult team members often act as a bridge to communicate patient and family needs to team members in other settings.” (3)
Expert teams are at the core of the vision for improved HPC in Ontario as described in the report from Ontario’s recent engagement process Advancing High Quality, High Value Hospice Palliative Care in Ontario (1).
Primary Care Providers
Primary care providers provide most of the care for patients requiring palliative care patients. It is therefore very important that these providers have an understanding of the principles of palliative care and are connected with the specialist level teams. In this context the term ‘primary care provider’ refers to family physicians, Community Health Centres, family health teams, walk in clinics etc.
As the need for Palliative care increases so will the need for Primary Care Physicians and primary care teams who are trained in Palliative care and can deliver this care in a
“shared care / collaborative care” model with the emerging expert teams. (3) Grief and Bereavement and Other Programs and Supports
It is noted that patients/families receiving palliative care will need to avail themselves of diagnostic, therapeutic and support services (mental health bereavement etc.). A description of the current availability and coordination of these services for palliative patients is beyond the scope of this current report, but these services are acknowledged as essential partners. Many HPC/EOLC Networks include many of these partners regularly at the table. (3)