End of Life Module Learning Plan

Transcription

1 End of Life Module Learning Plan End of Life Module Aims To improve the care of patients and families living with, suffering and dying from life-limiting and chronic illnesses by: Learner Objectives Identifying patients early who could benefit from a palliative approach. Enhancing GP confidence and communication skills to enable Advance Care Planning (ACP) conversations. Assessing patient and family needs from a palliative perspective. Identifying and referring appropriate patients to specialty palliative care and others for consultation and services. Understanding provider needs, clarifying roles, tools and resources for practice support and collaboration. Improving collaborative care planning, coordination and communication with clients/caregivers and with other local health care and community providers. Increasing physician knowledge of how they can support their own emotional well being. Improving the experience of the patient, family, physician, MOA and healthcare providers in End of Life care. Improve physician confidence related to End of Life care (e.g. care planning, forms, death certificates, etc.), By the end of this Module, the learner will be able to: 1. Engage primary providers working with patients with chronic diseases or advanced illness who would benefit from a palliative approach. 2. Promote collaborative practice in the provision of a palliative approach in CDM. 3. Identify patients with chronic disease who would benefit from a palliative approach. 4. Identify & become familiar with assessment and care planning tools and resources that support implementing a palliative approach. 5. Enable the initiation of advance care planning conversations. 6. Identify patients appropriate to refer for specialist palliative care consultation and service, and know how to access those services. 7. Identify, support and manage grief and bereavement in a patient s support network. Key Messages 1. It is important to be proactive about End of Life planning. 2. Palliative care is improved by a collaborative, team-based care approach. 3. A holistic approach to dying can help decrease fears and improve preparation for death.

2 End of Life PSP Module Content Pre-work: GPs to conduct Palliative Care and End of Life practice self-audit and read GPAC Guidelines Part 1, 2 and 3, Frail Elderly Guidelines Learning Session #1: IDENTIFICATION, COMMUNICIATION, ASSESSMENT 1. Introduction - Why do we need a Palliative Approach to chronic disease? 2. Patient s Voice 3. Module Aim 4. Philosophy of care (includes dying trajectories, incorporating palliative care with advancing disease. Key transitions) 5. Identification of patients needing palliative care (UK Gold Standards Framework) 6. Practice approach to care (e.g. know your patient, know what you plan to do with the patient, discuss briefly concept of registry) 7. Report back on practice self-audit results 8. Communication concurrent session for GPs: What is holding us back from bringing up the topic How do you approach the subject Advance Care Plan (My voice video and materials), No CPR 9. Communication and Making patients & families aware of local resources concurrent session for MOAs 10. Assessment: What are the patient s and families needs, desires etc Seniors Assessment Tool Palliative Performance Scale Pain/symptom diary Patient Outcome Scale Edmonton System Assessment Scale 11. Practice Support Program structure / GPSC governance & funding 12. Model for Improvement (Practice Aims, measures, action plan, narrative report) Action Period #1 Learning Session #2: PLANNING, COLLABORATION, Action Period #2: Learning Session #3: COLLABORATION 1. GPs have an initial discussion with a couple of patients (3-5) 2. MOA/Physician review office procedures to identify clients and track them 3. MOA use triggers list to identify potential EoL clients 4. Physician carry out Palliative Performance Scale (1-2) 5. MOA supported: Pain/symptom diary on a couple of patients (1-2) Patient Outcome Scale (POS) on a couple of patients (1-2) Edmonton Symptom Scale on a couple of patients (1-2) 6. MOA find out about local community based resources (e.g., hospice, internet etc) 7. Track measures during AP 1 1. Patient s Voice 2. Report back on action period activities Concurrent session GP e.g. conversation with 3-5 patients during AP 1 3. Report on action period. Concurrent session MOA e.g. experience in using tools (with MOA breakout) 4. Planning Palliative Care Plan Advance Care Directive MOST form Guidelines on use of and access to specialized medications Palliative Care medication kit Compassionate Care Benefits form 5. Planning Using the EoL Algorithm Home visits Good death Notification of Expected Death, BC Palliative Care Benefits form Collaboration Tool 6. Concurrent Sessions a. Symptom Management (physician breakout) Symptom Management Part 1: Pain & Dyspnea GPAC Palliative Care Part II symptom management b. MOA role in EoL Care (Concurrent MOA Breakout) 7. Develop and expand registry and office approach Registry Tools for communication 8. Planning for the Action Period 1. GPs and other health professionals try collaborative care approach for 3 5 patients 2. Patients (3-5) complete their Advance Care Plan 3. GPs try optimum referral process to nonpalliative specialist with 1 patient in local community 4. Expand registry 5. MOA supported: Pain/symptom diary on a couple of patients (1-2) Edmonton Symptom Scale on a couple of patients (1-2) Look back at charts to see how could have improved the death 6. Track measures during AP 2 1. Report back on action period activities 2. Collaborative planning session on improving local community services for EoL patients & families, collaborating with home care 3. How to support patient and family A) during terminal phase with local resources B) during grief and bereavement 4. Filling out of death certificates 5. Billing criteria for new incentive payments, with case study 6. Sustainability of clinical redesign changes in practice 7. What s next? Continuing the process

3 End of Life Module Learning Session 1 AGENDA Registration & Meal 25 minutes Introduction/Overview of End-of-Life module Didactic (10 min) Table Discussion 45 minutes Creating a patient registry - Patient identification - Group discussion: roles and responsibilities Facilitated Table Discussions 35 minutes Advanced Care Planning - My Voice 15 minutes BREAK 50 minutes Available tools: - Address Senior Assessment Tool - Palliative Performance Scale - Edmonton Symptom Assessment Scale - Work flow: algorithm and binder Facilitated Group Discussion Didactic (20 min) Didactic (35 min) Table Discussion 10 minutes Billing Didactic 45 minutes Action Planning Didactic (20 min) Individual and Group Planning (25 min) Total Education Time: 210 minutes (3.5 hours)

4 End of Life Module Learning Session 2 Registration AGENDA Presenter 15 minutes 35 minutes 45 minutes 30 minutes Voice of the Patient/Family Member/Community Story Patient Report back on Action Period Planning What needs to happen next? Handouts: End of Life Care Plan Template, MOST form, Compassionate Care Benefits Form, BC Palliative Care Benefits form Audience Stories (35 min) Table discussion Audience teams GP Facilitator Planning Using the EoL Algorithm Handouts: Front page of algorithm GP Facilitator 15 minutes BREAK 45 minutes BREAK OUT SESSIONS: PHYSICIAN: Symptom Management: Part 1 Pain & Dyspnea GPAC Palliative Care Part II symptom management Handouts: GPAC Part 2 Didactic (15 min Specialist or GP Facilitator 15 minutes MOA: End of Life Care - MOA Role Handouts: (see next page) Table Discussion PSP or MOA Facilitator Develop Office Approach Handouts: Office Huddle Didactic GP Facilitator 25 minutes Planning for the Action Period Handouts: Action Plan Sample Action Plan, Blank Action Plan Template, PDSA Template Table Discussion: Prepare plans for the action period (20 minutes) Didactic (5 min) Table discussion / planning (20 min) PSP RST Coordinator + GP Facilitator Total Education Time: 210 minutes (3.5 hours)

5 End of Life Module Learning Session 2 Assessment Tools (Forms in the chart insert): Seniors Assessment Tool Palliative Performance Scale (PPS) Edmonton Symptom Assessment Scale (ESAS) Pain and symptom diary Care Planning Forms (Form in the chart insert): End of Life Care Plan Template/MOA Flow sheet My Voice No CPR form BC Palliative Care Benefits Program Application Form Employment Insurance Compassionate Care Benefits Form Notification of Expected Death in Home Form Death Certificate Optional/Supporting Documents: MOA role Billing Codes Billing Guide for palliative care related incentives ESAS MOA handout (including script) Edmonton Symptom Assessment Scale (ESAS) Guidelines Script for Pain & Symptom Diary ACP Conversation Guide ACP Communication and Follow-up ACP Scripted Questions Cancer Management Flow Sheet Placeholder page for local resources Online Resource Guide

6 End of Life Module Learning Session 3 AGENDA 50 minutes Registration 15 minutes BREAK Handouts: Physician Health Program, Filling out death certificates Report Back on Action Period, Including Patient/Family Voice (50 minutes) 30 minutes Symptom Management: Part 2 Addressing the Question of Hydration (20 minutes) Group feedback facilitated discussion (50 min) GP/PSP Facilitator Specialist/GP presenter 35 minutes GPAC Palliative Care Part III Grief and Bereavement How to support patient and family (35 minutes) Didactic (35 min) Specialist/GP presenter 15 minutes Billing criteria for new incentive payments (15 minutes) 45 minutes Continuing the improvements in your local community (45 minutes) Table Discussion: 25 minute table discussion 35 minutes Sustainability of Clinical Redesign in Your Practice Table Discussion: 25 minute table discussion Total Education Time: 210 minutes (3.5 hours) Didactic Didactic (20 min) Table Discussion (25 min) Didactic (10 min) Table Discussion (25 min) GP/PSP presenter/faci litator GP/PSP presenter/faci litator