Advancing High Quality & High Value
Hospice Palliative Care
A Healthier Tomorrow
Presentation Overview
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Background
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End of Life Care Networks / South West Hospice Palliative Care
Network (2004)
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Provincial Declaration of Partnership and Commitment to Action (2011)
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From the declaration, the definition of what is Hospice Palliative Care is
When should it be considered?
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Provincial Hospice Palliative Care Structure, Deliverables and Targets
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South West LHIN Hospice Palliative Care Structure, Goals and Quality
Improvement Framework
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Original Mandate of end-of-life care networks
(MOHLTC, 2004)
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Broad system design
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Coordination and integration of services at the system level
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Promotion of service innovations
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South West Hospice Palliative Care (HPC) Network
Strategic Plan (2010 / 2011):
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Strategic Planning Priority Identification
Access to expert consultation in all communities and settings
Small steps, focus, don’t spread too thin Define model, replicate
Develop common goals across programs Shared communication portal
Understanding what each other does Consistent communication with patients and families
Based on consistent standards adopted by Network
Different intensity of training for generalists and specialists
Greater reach of existing programs (e.g. in colleges, university)
Funding to match educational requirements
Setting The Stage for Change Workshops
Provide a compelling case for investment of time, energy, and resources in HPC
Establish a vision that is aspirational but also practical
Focus Network’s modest resources on work that will yield the greatest results for patient and family care
Articulate key changes we wish to make Offer practical change management strategies
Develop a group of individuals interested in contributing to projects
Strategic Plan
Raise Awareness about HPC
Advance an integrated system of care Enhance Quality of work life for HPC Providers
Strengthen the Network’s ability to influence change
Sustain an infrastructure to support the network’s growth
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South West HPC Network
Key Milestones (2011 / 2012)
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A re-established network with a DRAFT Terms of Reference
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A new website
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A plan for palliative Nurse Practitioner resources
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A stakeholder scan of Hospice Palliative Care services in Grey and
Bruce Counties
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An indicator in the Integrated Health Services Plan for the South
West LHIN
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South West Hospice Palliative Care Network
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http://www.swpalliativecare.ca/index.asp
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The Declaration of Partnership and Commitment to
Action (2011)
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Organizations and care providers for
changing care delivery practices and
processes
LHINs for regional planning, performance
monitoring and establishing shared
organization accountability for outcomes
Ministry for policy consideration and
stewardship
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Overview of Hospice Palliative Care
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“Active total care of patients whose disease is not responsive to
curative treatment”
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WHO
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Incorporates active and compassionate therapies to comfort
individuals & families
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CHPCA, 2002
Where? Required in ALL CARE SETTINGS WHERE PEOPLE DIE (i.e.
where people are living their lives).
Who provides HPC? Provided by many professions, specialists and
primary care.
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When should Hospice Palliative Care be
considered?
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The Role of Hospice Palliative Care During
Illness/ Simultaneous Care
(from Canadian Hospice Palliative Care Association model)anyone with a life-limiting or life-threatening illness, (even while receiving active treatment)
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When should Hospice Palliative Care be
considered?
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New Model – Linked with Chronic Disease:
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Who should receive Hospice Palliative Care?
The “would you be surprised” question:
“Would you be surprised if this person died within the next year?”
...If “no” - appropriate for HPC.
“Symptoms that require attention?”
….If “yes” – HPC now.
(A palliative approach usually needs to begin earlier than 1 year prior to death
with Advance Care Planning etc.)
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Why focus on Palliative Care?
Effective
1. Clinical Focus
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reduced pain and symptoms, burden of care
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improved quality of life overall
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reduce burden of survivors
2. System Focus
Positive outcomes for system overall related to:
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Decreased ED visits
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Admission avoidance
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Measurable hospital savings through significant reductions in
pharmacy, laboratory and intensive care costs
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Vision from the Declaration of Partnership and
Commitment to Action (2011)
We need to develop a system that….
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better supports people with life-limiting illnesses and their families;
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dramatically improves their comfort, dignity and quality of life
preceding death; and
•
is based on collaboration and commitment across
all care settings
,
and between families, providers, academics, funders and policy
makers, with
shared ownership
of solutions and actions
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Six Themes
Declaration Priority #1:
Strengthen Accountability / Introduce Mechanisms for
Shared Accountability
• Accountability to integrate delivery as part of a virtual team
• Develop a standard template to ID shared accountability on teams
Clinical Level Cross
Sector Accountability
• Implement mechanism to ensure organizational accountability so palliative care is provided in each care setting
• Develop a standard collaboration template to codify organizational accountability to one another
Organizational Level
Cross Sector
Accountability
• Develop a comprehensive integrated HPC program in each LHIN that includes inter-agency
accountability
• ID Palliative Care as a regional priority and mandate minimum standards in all care settings
Regional Level
Governance
• Accountability agreement to ensure that
collaboration occurs at all levels of planning and service delivery
Establish accountability
with Regional
Declaration Priority #2:
Improve Integration and Continuity Across Care Settings
• Provide care through an inter-professional team approach working from a common care plan with a common information sharing mechanism
• Service Planning for teams – standardized delivery across all care settings; expectations in HSP
Accountability Agreements
Integrated Delivery
through teams
• Clarify expectations for standardized delivery across all care settings
• Align with CHPCA standards (screening tools, practice guides, best practice tools)
• Align with CDM initiatives
Common Processes and
Practices Developed
and Standardized
• Leverage technology solutions that currently exist as
enablers for integration and coordination
Use Innovative
Technology as an
Enabler of Integrated
Care Delivery
“Every care setting/ service, caring for dying patients
requires access to Specialist Level Hospice Palliative Care
Declaration Priority #3:
Strengthen Service Capacity and Human Capital in All
Care Settings
• Examine ways to strengthen and leverage access to palliative care expertise at all levels (primary, secondary, tertiary)
• Complete a gap analysis of what currently exists within each area
Strengthen Primary Delivery through Access to
Secondary and Tertiary Level Expertise
• Determine what resources are needed within each community to ensure access to palliative consult teams Provide access to Expert
Palliative care
• Operationalize the three Provider Roles in Palliative Care (CPHSA) (primary, secondary, tertiary)
• Deliver clear communication targeted at new and existing HHR and HSPs to ensure palliative competencies are met • Provide Education aimed at three streams
Consistent and Standard Education and
Competency requirements for all levels of care
• Identify coaching and mentorship roles required at each level of care provision
• Develop competencies for coaching/mentoring
• Establish a mentoring/coaching program in each inter-professional team
Skill and expertise in coaching, mentorship and
Declaration Priority #4:
Broaden Access and Increase Timeliness of Access
• Align with Chronic disease Continuum Model• Integrate with CCAC Population Based Model • Earlier care planning to support episodic issues Ensure Early Identification
and Access to supports and Care Options
• Develop a plan to identify people who are
marginalized who would benefit from palliative care services (e.g. First Nations, Street involved or homeless, unattached)
More Equitable Access for All Population groups
• Develop an integrated regional plan and model to deliver community rural palliative care – building upon local resources
• Leverage technology to improve access (e.g. OTN,THC, e-shift)
More Equitable Access Across Geographies
• Implement agreed upon benchmarks Create effective planning
Declaration Priority #5:
Strengthen Caregiver Supports
• Self Management Strategies
• Include client and family in care conferences
Build Client and
Caregiver
Empowerment and
Capacity
• Expand Bereavement services as an integral part of
the palliative team
Access to Services
• Make information specific to region accessible to
caregivers
• Examine ways to strengthen and leverage existing
on-the ground supports for informal caregivers
Information and
Support to
Caregivers
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Declaration Priority #6:
Build Public Awareness
• “Speak Up” – Advance Care Planning
• Open up discussion s about end of life and earlier referrals to Palliative care
• Develop communication strategies to assist health care providers in “truth telling”
Engage in
Public
Dialogue
• Central Hub:
• Place for information and sharing
• Customized information for different groups • Peer mentorship program for the public
Improve
Access to
Information
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Hospice Palliative Care
Provincial Steering Committee
LHINs Recognize need for Immediate Implementation
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Currently, 50% of all Ontario deaths occur in acute care, which is costly
and contrary to Ontarian’s preferences to die in other settings of choice
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Province wide outcome of a minimum 10% shift in deaths that occur in
acute care will have an approximate impact of $11 million in savings / cost
avoidance (Bending the Health Care Cost, 2010)
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Impact is further enhanced with a consideration of avoidable
hospitalizations, reduced length of stay, province-wide improvements could
result in net annual saving / cost avoidance of up to $70 M (ICCP
estimates)
LHINs have agreed to Core Set of Common
Deliverables
Significant level of variation in current palliative care across the province (delivery models, access, standards, etc.). To resolve this, LHINs have agreed to accomplish the following by March 2015:
1. Establish a regional palliative structure / program / network, with specialized
palliative and advanced chronic disease resources coordinated at the regional level
2. Implement a palliative care indicator as part of the MLPA
3. Implement a Palliative Balanced Scorecard
4. Established performance and outcome tracking and feedback at the client, provider and team level:
5. Accountability Agreements with Health Service Providers (HSPs) updated to support tracking of each HSPs contribution to the overall regional objectives / goals
6. Care coordination role implemented through collaboration with all palliative care HSPs across the continuum of care
7. Outreach processes established across all palliative care HSPs across the continuum of care to identify individuals with advanced chronic disease and connect them with an extended inter-professional team
Integration of New Community Based HPC Nurse
Practitioners into their Regional HPC Programs
Program Description / Goal
• Contribute to the best quality of life and death for palliative clients and their families and to
reduce avoidable ED visits and hospitalizations
• The program involves 24/7 coverage for palliative clients
Role of Nurse Practitioner
• Support Most Responsible Physician (MRP) to ensure continuity of care for individuals with
complex palliative needs across all care settings
• Provide consultation and mentorship
• Establish strong partnerships and create care connections with primary care, specialized palliative
care, acute care and community care
Target Population
• Clients with complex palliative needs or high risk characteristics (shared care clients receiving
direct care from NP)
• Clients with stable palliative needs (coordinated care clients where NP provides clinical expertise)
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Palliative NPs (continued)
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LHINs collectively support launching the new community-based palliative
care programs / networks
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All LHINs have outlined plans that:
• Enhance team-based care through integrating new NP positions into existing care teams • Enhance care coordination across all care settings and levels of care (primary, secondary,
tertiary)
• Compliment existing services to increase community service capacity to support individuals
in their homes Increase capacity 24/7 access to care support through integrating with existing team-based coverage
• Create NP/MD/FHT collaborative partnerships
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LHINs are leading the development of performance metrics for measuring
impact of the community-based palliative care NP program.
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LHINs support Ministry to Develop an Integrated DATA
Strategy to Measure Progress Relative to Key Targets
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LHIN leadership for performance measurement would be optimized to strengthen alignment across multiple initiatives currently examining palliative indicators
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Big Dot Aim Indicator
This aim is defined as a 10% reduction in the total number of hospital days
attributed to palliative care, and is based on the following methodology:
• Averaged 3 years of acute in-patient days (total days) to determine 10% reduction
in Total Days
• Baseline = Average Total Days over last 3 years (2009-2012) • Total Days = Total ACUTE Days and Total ALC Days
• Rate of growth accounted for based on 2011/2012 rate of change at 3.7% • Patients identified as palliative using ICD-10CA code Z51^^
• Using discharge disposition of “death” was not considered as it does not distinguish
patients hospitalized for palliative care
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Supportive Measures for Big Dot Aim
Supportive measures have been identified to reflect the need to increase
“supported” end of life care and ensure quality of care and patient experience:
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# of patients discharged home with support ▲
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# of patients discharged home without support ▼
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# of ALC days (subset of total days including total LOS) ▼
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# Average total LOS ▼
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# of patients died in hospital▼
South West LHIN Hospice Palliative Care Services
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In the South West, 360 people (17%) died at home in Q4 2010/11.
Almost 2 years later, Q3 2012/13, 470 people (22.3%) died at home.
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The provincial comparator is 21.4% in Q4 2010/11 and 24.8% in Q3
2012/13.
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36.5 – 39.9 % of palliative patients in the South West LHIN
experienced multiple acute care admissions in the last 3 months of
life (2011/12)
(Data Source(s): Discharge Abstract Database (DAD), Continuing Care Reporting System (CCRS), National Ambulatory Care Reporting System (NACRS), National Rehabilitation System (NRS), Ontario Mental Health Reporting System (OMHRS), CIHI, extracted from Health Data Server, MOHLTC, May 2013. Registered Persons Database (RPDB), Claims History Database (CHDB), MOHLTC, extracted May 2013. Home Care Database (HCD), OACCAC, extracted from Health Data Server, MOHLTC, May 2013. Health Based Allocation Model (HBAM) 2011/12 CCAC services cost, MOHLTC, May 2013
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Amongst palliative care hospital encounters in Q1 2013, 20% of days
in hospital were ALC
(DATA Source: Hospital Discharges Main Table, Ontario Ministry of Health and Long Term Care, Intellihealth Ontario, Data Extracted November 28, 2013)
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Ministry / LHIN Development of Residential
Hospice (RH) Policy Framework
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(RH) Policy Framework to establish a more strategic and consistent
approach to RHs
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LHINs see RHs as important for system transformation in terms of
providing a more cost effective and more appropriate care setting than
hospital-based palliative care.
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By developing a more robust RH presence in targeted communities, LHINs
expect to significantly reduce hospital expenditures and achieve net system
savings.
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By updating RH policy to align with LHIN integration strategies as well as
the ministry’s fiscal plan, LHIN and stakeholder expectations can be more
strategically managed while improving access and equity for more
Ontarians.
Coalition Implementing Complementary Actions
Advancing the Priorities within the Declaration
QHPCCO (Coalition) Actions from the Declaration include:
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Supporting early identification of care needs through expanding provincial
representation to include chronic disease associations
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Strengthening caregiver supports through:
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Identifying best and leading workplace policies / practices across
Ontario that support employees to take compassionate leave
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Centrally coordinating common information guides and develop a
common toolkit for caregivers
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Promote the adoption of evidence based best practices and build readiness
to implement cross-sector accountability
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Working with partners to explore options and seek opportunities for
increasing general public’s understanding and awareness
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Ministry / LHIN Commitment to Collaborative Leadership
Structure
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*In order to ensure accountability, the collaborative leadership would establish an annual public report on the implementation, progress, impact and performance results against action commitments.
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South West LHIN
Integrated Health Service Plan (IHSP) 2013 - 2016
IHSP Strategic Direction #2 emphasizing HPC QI
work
Improve Coordination and Transitions of Care for Those Most Dependent on Health Services
Objectives:
1. Continually respond to the needs of the evolving population of people with the
greatest unmet health care needs utilizing a significant proportion of the health care resources
2. Create a collaborative person-centered response to better support the growing population of people living with chronic conditions and those at risk
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South West LHIN Goals
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To understand the service delivery model we are trying to create;
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To create a Network structure that has the accountability, authority
and mandate to achieve the goals outlined in the Declaration of
Partnership; and
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To align the Network lead position and other required resources to
support achievement of goals
Hospitals - Acute Care (including host hospital for RCP) Hospitals - Complex Continuing Care Long Term Care Homes Patients’ Home* (CCAC & CSPA etc.) Residential Hospices
Hospice Palliative Care Program • Visiting Physician Program
• Expert HPC Nurses & Nurse Practitioners • Expert Multidisciplinary Professionals
• Palliative Pain and Symptom Management Consultation and Education Programs – cross sector education and consultation to formal care providers
• Volunteer Hospice Programs • Community Hospices
• Outpatient Clinics • Etc.
Cross sector
*- “Patient’s home” refers to any location where patient is residing (outside of settings included here). This may be a Community Living residence, Group home etc.
** - “Outpatients” refers to ambulatory & ‘transportable’ patients & families
Next Steps: Regional Hospice Palliative Care Program Vision
Ambulatory care/Day Programs and Community Support Services
24/7 care settings
35Patient
and
Family
Primary Care
Multi-Community
Regional
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Tertiary Care Palliative
Program – LHSC, Parkwood
•
NP Team
•
Paediatric Palliative
Consultation Program
• Palliative NPs
• Palliative Specialty Physicians • Residential Hospice
• Palliative Pain and Symptom Management Consultation Program
• Primary Care • Care Coordinators
• Community Care Service Providers – CAPCE Trained • Hospice Volunteers
• Community Hospitals • Clergy
Teams Comprised of:
South West LHIN Hospice Palliative Care Program
Consultation and support to Primary Care Available 24/7
Mobile
Support primary care team as key service provider
Education to drive best practice
Daily, hands on 24/7 primary care for palliative patients in their home
Intensive Care Coordination
Consultation for complex palliative issues Research and evaluation
Drive clinical practice standards
• Leadership • Governance • Strategic priorities • Priority setting • Partnering • Defining Accountability • Health Policy
• Best Practices in non-Clinical and clinical Care • Performance measurement • Research
• ‘Relentlessly Telling the Story’ • Communicating
• People/Stakeholders
• eHealth
• Standardization of EMR/ EPR
• Enabling measurement through Business intelligence/decision support • Performance based incentives • Recognition (Quality Awards) • Celebrating • Knowledge and Translation
• Education & Training • Change Management
South West LHIN
Quality Improvement Enabling Framework
(QIEF)
Person Centered ‘Right Action and Right Intervention’ Leading Building System Capacity Applying evidence decision making Enhancing Health Information Systems Engaging MotivatingQuality Framework References 2011: Capital District Health Authority, Alberta Health Services, National Health System, Ontario Council on Community Health Accreditation and Niagara Health System, IHI, Baldridge Performance Excellence Program
• Accountability to integrate delivery as part of a virtual team • Comprehensive integrated HPC
program that includes inter-agency accountability • Accountability agreement to
ensure collaboration
• Standardized delivery across all care settings • Align with CHPCA
standards (screening tools, practice guides, best practice tools)
• Benchmarks for access • Build primary care physicians
into the community based team – community outreach • Partner with existing
provincial palliative care initiatives in LTC
• Identify and engage people who are marginalized who would benefit from care • Include client and family in
care conferences
• Leverage technology solutions as enablers for integration and coordination
• Leverage technology to improve access (e.g.) ONT, e-shift)
• Celebrate success and QI achievements
• Strengthen and leverage access to palliative care expertise at all levels
• Establish mentoring / coaching program in each interprofessional team
South West LHIN
QIEF & Alignment to
Declaration of Partnership (2011)
Person Centered ‘Right Action and Right Intervention’ Leading Building System Capacity Applying evidence decision making Enhancing Health Information Systems Engaging MotivatingA Healthier Tomorrow
Improving the Experience for Individuals receiving
Hospice Palliative Care
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Turning experiences in action!
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The Experience Based Design approach is different from many other
improvement or change initiatives in that it encourages you to work closely
with both patients, carers and staff in developing a better experience for all.
•
Involving patients, carers and staff as partners in design in solutions for the
Hospice Palliative Care service can lead great improvements and healthcare
journey / experiences for all.
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http://www.hqsc.govt.nz/assets/Consumer- Engagement/Partners-in-Care-Resource-page/NHS-EBD-Guide-30.1.2009.pdf
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Opportunities (EBD):
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Opportunities (E-Health):
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Clinical Connect
41
•
a secure web portal, or
Viewer, that makes it
possible for health care
professionals to see a
patient’s medical
information from separate
information systems.
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Opportunities (E-Health):
•
E-Shift
42•
is an innovative
program launched in
2010 where (PSWs)
receive specialized
training and technology
tools to provide clients
bed-side, in the home
care end-of-life stage
care.
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Opportunities (E-Health):
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HealthChat.ca
43
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new online tool enables
multiple users to create a
profile (or space) where
information can be shared
and used to communicate
or “chat.”
Hospice Palliative Care Leadership
Committee
Oversight Committee Responsible for: • System Design
• Capacity Planning
• Learning and Development • Performance
• Measures/Monitoring • Clinical Standardization
• Clinical Coordination / Common Clinical Processes
Care Collaborative: Local palliative care representatives including Executive Sponsor(s)/ members that are key local decision-makers
Activities: Local service planning for palliative care within each community; identify local system capacity needs/gaps; local CQI; oversight of local capacity building activities, etc.
HPC Lead
South West LHIN
Structure
ToR & work plan with each collaborative Oxford Hospice Palliative Care Collaborative Grey Bruce Hospice Palliative Care Collaborative Elgin Hospice Palliative Care Collaborative Huron Perth Hospice Palliative Care Collaborative Middlesex London Hospice Palliative Care Collaborative
