Integration of a Palliative Approach:

Transcription

1 Integration of a Palliative Approach: A Look at Serious Illness 2018 CHPCA Learning Institute June 2018

2 Objectives 1. Explore what is meant by a palliative approach 2. Describe different conceptual models of integration 3. Review evidence of the benefit of early integration of palliative care 4. Discuss practical approaches to integration of palliative care

3 Integration the act of bringing together smaller components into a single system that functions as one

4 Two Solitudes General Medicine o Curative therapies o Clinical trials, scientific basis o high-tech therapies o Algorithms o Disease oriented Palliative Care o Grass-roots movement o Dissatisfaction with modern medicine s way of caring for terminally ill patient o An alternative system of whole person care

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7 Two Solitudes General Medicine o ACTIVE o Life prolonging o Aggressive treatment Palliative Care o Passive o Nothing more we can do o End-of-Life o Death Panels

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9 Perceptions of palliative care among patients with advanced cancer and their caregivers Death, end of life Comfort care No more choices, nothing left to do Loss of autonomy A place to die Unsure of meaning Zimmermann et al. CMAJ 2016

10 Initial reactions to palliative care Shock and fear Resistance to palliative care Not relevant for me Zimmermann et al. CMAJ 2016

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12 Vision: The Way Forward National Framework All people in Canada who are aging and/or have chronic life-limiting conditions will have the opportunity to benefit from the integrated palliative approach to care within their community.

13 Palliative Approach One way of conceptualizing care for those with advancing chronic illnesses who may not require specialized palliative care services and who would benefit from having their end of life care concerns identified much earlier in the illness trajectory Sawatzky et al, BMC Palliative Care 2016

14 Principles Patient- and family-centred care Focuses on person, not just disease Quality of life is primary goal Sawatzky et al, BMC Palliative Care 2016

15 Essential Characteristics of a Palliative Approach An upstream orientation to care Adaptation of palliative care knowledge & expertise Operationalization of a palliative approach through integration and contextualization within healthcare systems Sawatzky et al, BMC Palliative Care 2016

16 Conditions Required for Upstream Orientation Recognition & understanding of different chronic illness trajectories Identification of where people are on those trajectories Sawatzky et al, BMC Palliative Care 2016

17 Palliative Approach Patient identification Symptom screening Functional status monitoring GOC/ACP discussion/documentation Care planning Information sharing Plan for emergencies

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19 Specialist Palliative Care Palliative Care provided by those who have undergone specific training &/or accreditation in palliative care, working in the context of an expert interdisciplinary team of health professionals. New Zealand Health Information Standards Organization

20 Generalist Palliative Care Generalist palliative care is palliative care provided as an integral part of standard clinical practice by any health professional who is not part of a specialist palliative care team. New Zealand Health Information Standards Organization

21 Palliative Care Expertise Tertiary Care Secondary Care Specialized Generalist Primary Care Palliative Approach

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23 Conceptual Models of Integration 1.Time-based models 2.Provider-based model 3.Issue-based model

24 Time-Based Models

25 Old Model Active Disease Oriented Treatment Palliative Care Bereavement Care Presentation 6m Death

26 Simultaneous Model of Care: Palliative Care Begins at Presentation Therapies to Modify Disease End-of-Life Care Palliative Care Presentation Therapies to relieve suffering & improve Quality of Life 6m Death Bereavement Care

27 Randomized Trials of Early Specialty Palliative Care in Patients with Cancer Decreased: emergency room visits Hospital admissions ICU stays Symptoms Costs Increased: Quality of Life Mood Satisfaction Survival

28 Provider-Based Model

29 Provider-Based Model Tertiary Care Secondary Care Primary Care I n t e g r a t i o n

30 Primary Level Available in every care setting Interprofessional primary care providers have a basic understanding of palliative care: o Able to identify, refer and provide the core competencies o Able to address physical, emotional, social, cultural and spiritual needs o Provide clinical management and care coordination including assessment, triage and referral for patients with uncomplicated needs o Have access to specialized services, and links with secondary and/or tertiary providers CCO s Model of Palliative Care 30

31 Secondary Level Interprofessional health care providers with basic training and significant experience in palliative oncology care: o Provide consultation, support, information and mentorship to primary care providers o Able to identify, and refer, patients requiring specialist care o Care for patients/families whose needs exceed the capability of primary care providers (e.g., sporadic exacerbations of pain and other symptoms) CCO s Model of Palliative Care 31

32 Tertiary Level Required in cancer centres, academic hospitals, tertiary palliative units Includes experts in palliative care available to: o consult to secondary experts and primary providers on difficult to manage cases o educate and train secondary experts o conduct research o develop advocacy strategies Provides a level of service for: o specialized, frequent and skilled assessments o interventions over a short period of time o diagnostic tests, complex treatments or invasive procedures (Includes tertiary interventions, such as surgery and acute medical interventions.) CCO s Model of Palliative Care 32

33 Issue-Based Models

34 Solo Practice Hui et al. 2015

35 Congress Practice Hui et al. 2015

36 Integrated Care Model Hui et al. 2015

37 System-based Model

38 System-based Model Patient-centric model Pre-defined criteria regardless of underlying disease Streamline referral process to ensure high level of support

39 Optimal Model

40 Optimal Model(S) Remote Rural Urban

41 Integration the act of bringing together smaller components into a single system that functions as one

42 Optimal Model Principles: operson-centred care otimely care oquality care oneeds-based care VS prognosis o Continuous care oequitable access

43 The Bowtie Model of 21 st Century Palliative Approach to Care Disease Management Cure Control Symptom Management and Supportive Care Survivorship Hospice Palliative Care

44 Integration of Palliative Approach Culture change for health professionals and public Upstream orientation Contextualize to person & setting

45 Questions???