South East LHIN Palliative Care Priorities and Resources

Transcription

1 South East LHIN Palliative Care Priorities and Resources Lori Van Manen Regional Palliative Care Network Lead & Natalie Kondor Palliative Physician Regional Palliative Care Rounds Nov 17, 2017

2 Objectives: 1. Understand the mandates of the provincial and regional networks 2. Describe the goals, priorities, & system level measures in the Ontario Palliative Care Network s Action Plan 3. Know the priorities identified by the Regional Palliative Care Network in South East 4. Review pertinent regional palliative care resources No Conflict of Interest or Commercial Interest to Declare

3 Current State: In the South East LHIN, there were <5000 individuals (4,720) who died between April 2015 and March 2016 Excluding traumatic deaths, just a little over half of these individuals (57%) received palliative care services on at least one occasion Of the 2,691 individuals who received palliative care services, almost half (48.6%) died in hospital, and ~two-thirds (65%) spent time as an acute inpatient in their last month of life Of those that received palliative care services, almost 3/4 (73%) received home care visits in their last month of life The majority (about 54%) had an unplanned visit to the ED in their last month of life For all 4,720 decedents, the average time spent as an acute inpatient was over one week (8.7 days) during the last month of life. 3

4 The Ontario Palliative Care Network Strategy/Vision: To develop a coordinated, standardized approach to high-quality, sustainable and person-centred hospice palliative care for all Ontarians, regardless of age or disease type. SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK

5 THE MANDATE OF THE ONTARIO PALLIATIVE CARE NETWORK Be a principal advisor to government for quality, coordinated, hospice palliative care in Ontario Be accountable for quality improvement, data and performance measurement and system level coordination of hospice palliative care in Ontario Support regional implementation of high-quality, highvalue hospice palliative care

6 REGIONAL PALLIATIVE CARE NETWORKS ACCOUNTABILITY & COMPOSITION The 14 Regional Palliative Care Networks will work with stakeholders and providers to ensure delivery of consistent personcentred care in their region using the following framework: Joint accountability to LHIN CEO and RVP Standardized accountability model Joint reporting on network activities to LHIN CEO and RVP A governance model of mixed leadership Multidisciplinary clinical co-leads and Network Director/Lead Build on what is already in place in the regions OPCN Executive Oversight LHIN CEO RCP RVP South East RPCN Steering Committee Regional Palliative Care Network Builds on existing structures Includes: Network Director/Lead Multidisciplinary Clinical Co-Leads Governance Table

7 The South East Regional Palliative Care Network (South East RPCN) is: A partnership of community stakeholders, care providers, patients, families and caregivers in South Eastern Ontario who are working together to ensure that there is a coordinated, standardized approach for the delivery of hospice palliative care services. As a community of partners, the South East RPCN is committed to the delivery of highquality, high value palliative care in the region. To find out more please visit our website South East RPCN.

8

9 OPCN Goals for 3 Year Action Plan SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK

10 Four Priority Areas Have Been Identified for the 3-Year Timeline of the Action Plan: SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK 10

11 OPCN Big Dot Indicators: SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK 11

12 Description of Cohort: The end-of-life cohort (also referred to as decedents ) consists of all patients who died during the 2015/16 fiscal year (excluding traumatic deaths) Nine data sources were used to identify patients who died during the time frame In cases where multiple death records exist for the same patient, the death date/setting was selected based on a hierarchical approach that considered the intensity of care provided. Patients (or decedents) who received palliative care include all patients who were designated ("flagged") palliative and/or received at least one palliative service in their last year of life Five data sources were used to determine if palliative care was provided and/or designated: OACCAC, CCRS, DAD, NACRS, OHIP. In the palliative/non-palliative stratification, services received by patients in the palliative care cohort may have occurred before or after they were flagged as palliative. 12

13 Big Dot 1: Percentage of Decedents who Died in Hospital As of FY2015/16, in the South East LHIN, 41.7% of decedents died in the hospital 41.7% The South East LHIN has set their target at 39% for 2019; the provincial target was set at 40%. SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK 13

14 Percent of decedents who died in hospital (FY2015/16) by Sub-Region The South East LHIN s rate (41.7%) is lower than the provincial rate of 45.1% (see figure to the right). Of the five sub-regions, RFL&A had the largest proportion of deaths in hospital with 47.2%; Rural Hastings had the lowest proportion with 34.1%. *Hospital includes inpatient and emergency departments 14

15 Big Dot 2: Percent of Community Dwelling Decedents who received physician home visits and/or The South East LHIN has set their target at 24% for 2019; the provincial target was set at 31.9%. Note: home visits do not include nursing or PSW shifts. SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK 15

16 Percent of community dwelling decedents who received physician home visits and/or palliative home care in the last 90 days of life (FY2015/16)* The South East LHIN has observed a slight increase in the number of decedents who received home visits within the last 90 days of life, from 18.5% in FY2012/13 to 19.4% in FY2015/16. Comparatively, the provincial values have been consistently higher at 22.9% in 2012/13 and 25.8% in 2015/16. *Sub-Region level data has not yet been developed for this indicator 16

17 The South East LHIN has set their target at 50% for % of decedents with one or more ED visits for 2019 and 18% for two or more ED visits; the provincial targets were set at 49.6% and 14.8%, respectively. 1 or more 2 or more SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK 17

18 3. Percent of decedents that had a) one or more ED visits or b) two or more ED visits in the last 30 days of life (FY2015/16) The South East LHIN has seen a slight decrease in the % of decedents with one or more ED visits in the last 30 days of life from FY2012/13 to 2015/16 (see graph to right). Additionally, the South East LHIN saw a slight decrease in % of decedents with two or more ED visits in the last 30 days of life over the same timeframe. 18

19 3. Percent of decedents that had one or more emergency (ED) visits Sub-Region View (FY2015/16) Across the South East LHIN sub-regions, Lanark, Leeds & Grenville had the highest percent of decedents with one or more ED visits in the last 30 days of life with 58.4%; this was above the provincial rate of 55.3%. Kingston and Rural Hastings sub-regions had the lowest percent at 47.7% and 48.0%, respectively. These are the only two sub-regions currently below the 2019 South East LHIN target. SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK 19

20 OPCN 3-Year Action Plan Development (for Release in Nov/Dec 2017): Plan is in evolution 39 Action Items have been identified some provincial, some regional RPCNs are considering where and how the actions relate to our LHIN area and current regional work plan, and How to bring at least one of the regionalfocused action items to fruition 20

21 Engaging with Partners to Develop the South East Regional Work Plan:

22 Patients, Families, Caregivers at the Centre of All that we Do

23 Priority Projects for the South East Regional Palliative Care Network Model Theme - Gaps/Priorities 1. Coordinated Care: Standardize the Process of Care Delivery Incorporates several gaps such as Single Point of Contact/Navigator, Care Conferences, Standard Assessment Tools for patients & caregivers, caregiver supports and resources, standard discharge summary for caregiver 2. Better Communication within Circle of Care: Better communication among providers and with patients/caregivers; centralized, standardized, unified technology, single record 3. Access to Care 24/7 Pharmacy coverage, a formalized on call strategy, NP call rotation & access to palliative care walk-in 4. Residential Hospice Capacity & Standards Evaluate current hospice beds against criteria/standards (and develop an action plan for addressing gaps) & review business plans for new residential hospice against a guiding document & make recommendations to the Steering Committee. 5. Competency Building Standardized training required to build competency and standardize service provider (and volunteer) skills Working Group: Sub-Region/Regional Pilot work: LLG Sub-Region Executive Sponsor: Peter McKenna Team Lead: Ruth Dimopoulus Pilot work: Rural Hastings Sub-Region Executive Sponsor: Dr. Janet Webb Team Lead: Alicia McCullum Pilot work: Quinte Sub-Region Executive Sponsor: Wendy Parker Team Lead: Mary Woodman Regional Working Group Executive Sponsor: Allen Prowse Team Lead: Maggie George Regional Working Group Executive Sponsor: Dr. Ingrid Harle Team Lead: Cynthia Johnston SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK

24 SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK 24

25 SOUTH EAST REGIONAL PALLIATIVE CARE NETWORK 25

26 OPCN Action Plan Mapped to 5 Priority Projects 12/39 action plan items are regional (RPCN) responsibilities All 12 regional actions map directly to one or more of our priority projects OPCN outputs that will be available by Q2 (summer) 2018: Identification of populations that would benefit from palliative care Tool for early identification of patients who could benefit from palliative care HQO Quality Standard for Palliative Care Platform to house regional directories of palliative care resources Patient caregiver resources 26

27 Health Quality Ontario Quality Standard for Palliative Care (Spring 2018) 27

28 Resources: Home & Community Care, South East LHIN (formerly South CCAC) Leadership Team: Joanne Billing, Vice President, Home and Community Care, South East LHIN Laurie French, Director, Special Programs, South East LHIN Juli Heney, Manager, Client Services- Palliative Care Program, Home and Community Care, South East LHIN 28

29 Palliative Pain & Symptom Management Consultation Service Provincially funded, sponsor agency is South East LHIN Case-based education & mentoring to health care providers working in community agencies, LTCH s, CHC s and FHT s Goal is to build capacity among front-line care providers who are supporting individuals and families living with a life-limiting, lifethreatening illness Bedside consultation and mentorship to professional caregivers. Provides recommendations and resources to guide care. Promotes use of evidence based resources such as CCO Symptom Management Guides to Practice & Collaborative Care Plan

30 Palliative Pain & Symptom Management Consultant Contact Information Available days, Monday-Friday from 8:30 am 4:30 pm Currently, three full-time equivalent consultants in South East LHIN in Belleville, Kingston, and Brockville (plan is to have 5) Consultant Names: Belleville area: Jenni-Ann Logan Kingston area: Kimberley Volk Brockville area: Suzanne Jensen Process for consultation service requests: Fax a PPSMC Referral form obtained on our website to: , or Call the PPSMC referral Toll Free Line at:

31 Reminder: *Service requests for Long Term Care Home residents are supported by contacting the NP/Nurse Led Outreach Team, however, consultation services for pain and symptom management issues of LTCH residents go through the PPSMC referral stream 31

32 Hospice Palliative Care Nurse Practitioner Program: A Shared Care Model Program aim: To reduce hospitalization and avoidable emergency department visits for patients requiring Hospice Palliative Care (HPC) The Nurse Practitioner enhances quality of HPC by: Working collaboratively to provide on-going whole-person care Providing optimal pain and symptom management Delivering comprehensive evidence-based HPC to patients and their families closer to home, in their care setting of choice Referral Process: Complete a Service Request Form, obtained through website Request HPC NP Service and include reason for request Fax to ; include any relevant medical history, most responsible Primary Care Provider, updated medication list, latest consult notes, etc. Care Coordinator will confirm the shared care agreement after confirming with NP

33 Hospice Palliative Care Nurse Practitioners Contact Information: Valerie Cooper Kingston and Rural Frontenac, Lennox and Addington Currently accepting referrals for shared care in the Central region of the South East LHIN Tel: Ext 4214 Toll Free: Amber Babcock Quinte Currently accepting referrals for shared care in the West region of the South East LHIN Tel: ext.2281 Toll Free: Alice Howarth Rideau Tay and Thousand Islands Currently accepting referrals in the East region of the South East LHIN x 5242 Toll Free: alice.howarth@lhins.on.ca Clarissa Townsend - Rural Hastings Clarissa is well known to our Rural Hastings partners; she will be returning in the North West region of the South East LHIN in the coming months.

34

35 OMS Medical Pharmacies Are the suppliers of all Symptom Response Kits for SE LHIN Have contract with SE LHIN for all CADDs for SE LHIN (Medical Arts Pharmacy formerly held this contract) To order injectable meds: Fax orders to South East LHIN Home and Community Care (H&CC) H&CC forwards the Rx to Medical Pharmacies Medical Pharmacies delivers medications to patient s home *Can still order injectable medications from independent pharmacy but must inform H&CC of that plan to avoid double-ordering of meds

36 OMS Medical Pharmacies, Cont d SRKs and CADDs are delivered free of charge to patient (often this is true for injectable meds as well, if delivered with SRK, CADD or equipment ) Hours of Operation: Monday to Sunday 8am-8pm. Tel: , Fax: ,

37