Discussion Paper: Multidimensional Models of Hospice Palliative Care in Ontario. Sector Specific Models of Hospice Palliative Care (HPC):

Transcription

1 Discussion Paper: Multidimensional Models of Hospice Palliative Care in Ontario Part Three of Three Parts Sector Specific Models of Hospice Palliative Care (HPC): Current Status & State of Readiness for Change February 2012 Prepared by: Beth Lambie for the Ontario College of Family Physicians

2 Acknowledgements This discussion paper was prepared by Beth Lambie for the Ontario College of Family Physicians. Thanks to: Gary Switzer and Bill MacLeod, Local Health Integration Network CEOs, for conducting the LHIN Palliative Care Survey referenced in this paper, LHIN staff from each region who completed the survey referenced in this paper, Jan Kasperski from the Ontario College of Family Physicians and Julie Darnay, consultant, for encouraging completion of this paper, Each of the Regional End-of-Life / Hospice Palliative Care Networks for completing the regional reports referenced in this paper and for providing feedback to the discussion paper, Donna Laevens-Van West, Betty Smallwood and Maggie George for editorial assistance, Erie St. Clair End of Life Care Network (ESC EOLCN): o sections of this discussion paper were adapted from earlier ESC EOLCN reports o members of the ESC EOLCN provided vetting for this current discussion paper.

3 Discussion Paper February 2012 Multidimensional Models of Hospice Palliative Care (HPC) in Ontario Part Three Sector Specific Models of HPC TABLE OF CONTENTS List of Tables i EXECUTIVE SUMMARY ii SECTION 1 - OVERVIEW Purpose 1 Information Sources and Review Process..2 Why examine models of care by sectors?.3 Elements of Sector Specific Models of Palliative Care in Ontario..4 SECTION 2 - ACUTE CARE (INCLUDING HPC TERTIARY CARE) Background and Context...5 Description of Core Elements of Acute Care Models of HPC.5 Future System Role of Acute Care in Palliative Care Service Delivery Preferred Model of Care and Comparative Cost of typical models..11 SECTION 3 - COMPLEX CONTINUING CARE Background and Context...11 Description of Core Elements of Complex Continuing Care Models of HPC 11 Future System Role of Complex Continuing Care in Palliative Care Service Delivery SECTION4 LONG TERM CARE HOMES Background and Context.16 Description of Core Elements of Long Term Care Home Models of HPC.. 16 Future System Role of LTCHs in Palliative Care Service Delivery.. 18

4 SECTION 5 RESIDENTIAL HOSPICES Background and Context.20 Description of Core Elements of Residential Hospice Models of HPC 20 Future System Role of Residential Hospices in Palliative Care Service Delivery...24 SECTION 6 CARE IN THE HOME- COMMUNITY CARE ACCESS CENTRES (CCAC) AND COMMUNITY SERVICE PROVIDER AGENCIES (CSPA) AND SPECIALIST LEVEL ACCESS Background and Context..25 Description of Core Elements of In-Home Models of HPC Future System Role of CCAC and Community Services Provider Agencies in Palliative Care Service Delivery SECTION 7 OTHER HPC SERVICES (non 24/7 care settings) GENERAL DESCRIPTION OF MODELS OF SERVICE Regional Cancer Centres.31 Outpatient Palliative Care Clinics/Consultation Services...33 Volunteer Visiting Hospice Program (VHP Community Support Service (CSS) Funded Service Palliative Pain and Symptom Management Consultation Program (PPSMCP)..34 /Hospice Day Programs...34 Expert Teams..35 Primary Care Providers Grief and Bereavement and Other Programs and Supports 36 SECTION 8 SUMMARY AND READINESS FOR NEXT STEPS...36

5 List of Tables Table 1 - Summary of Key Elements of a Comprehensive Description of a Model of HPC at the SECTOR-SPECIFIC LEVEL in Ontario 4 Table 2 - Sector: ACUTE CARE HOSPITAL 10 Table 3 - COMPLEX CONTINUING CARE- HOSPITAL 15 Table 4 - Sector: LONG TERM CARE HOMES..19 Table 5 - Sector RESIDENTIAL HOSPICES 23 Table 6 - Sector CARE IN PATIENTS OWN HOME COMMUNITY CARE ACCESS CENTRE & COMMUNITY SERVICE PROVIDER AGENCIES (CSPA)..29 i

6 EXECUTIVE SUMMARY Discussion Paper February 2012 Multidimensional Models of Hospice Palliative Care (HPC) in Ontario Part Three Sector Specific Models of HPC Purpose This discussion paper reviews models of care in hospice palliative care (HPC) in Ontario. It aims to provide insight into our state of readiness for the next steps in evolving to a new model of care. This Part Three of the discussion paper focuses on the sector-specific level. It uses the multidimensional sector-specific model of HPC described in Part One to compare our current state with our aspirational model of care as described in the report from Ontario s recent engagement process Advancing High Quality, High Value Hospice Palliative Care in Ontario (16). The multidimensional sector-specific model checklist is used as a practical proxy for the narrative and diagrammatic descriptions of our aspirational model. Outcomes of this Part Three provide practical specificity in determining where we are between the extremes of the current model and proposed new model in terms of readiness for next steps (Note: next steps are articulated in Advancing High Quality, High Value Hospice Palliative Care in Ontario (16)). Current Model: Individuals with advanced chronic disease(s) or complex care needs receive care that is reactive, targeted, diseasefocused, centering on curative treatment, and delivered by multiple, siloed, individual providers in distinct, acute episodes. (1) Practical Specificity re. Sector readiness Proposed New Model: Adults and children with advanced or EOL chronic disease(s) and their informal support network will receive care and support that is proactive, holistic, person and family-focused, centering on quality of life and symptom management issues, and delivered by a virtually integrated inter-professional team in a coordinated, continually-updated care plan, that encompasses all care settings in which the client receives care. (1) ii

7 This discussion takes place in three parts: Part One - Presents a practical, check list / template, with core elements to use in describing and creating HPC models of care at a regional level and a sector specific level.(see previous discussion paper Part One for details) Part Two and Part Three Expand upon each of these core elements and apply these checklists / templates to review current status of HPC models of care at a regional level and at a sector specific level (This paper is Part Three sector specific level ; see previous discussion paper Part Two for LHIN level details) By reviewing current status in this systematic way insight is gained into where we need to focus attention at both the regional and sector specific levels. Why examine models of care by sectors? This section examines Models of Care for hospice palliative care in Ontario, by sector. Palliative Care is required and provided in virtually all care settings. Health and social care in Ontario is delivered by independent sectors and by independent service providers, each with its own Board of Directors, individual mandate, operational imperatives and strategic directions. (1) If we are to make changes in the system of palliative care we must engage specific sectors who have the operational responsibility for implementing changes within their individual care settings and services. Information Sources: Information for this review has been culled and collated from many sources including: Three province-wide HPC surveys completed in the past 3 years (2011, 2010, 2009), LHIN-specific HPC reports, documents, presentations, websites from across Ontario. Each source was reviewed for reference to models of HPC (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17), Minutes and discussion notes from PEOLCN and QHPCCO meetings, Sector-specific / organization specific websites and reports, Outcomes from discussions with key informants, Selected descriptions of models of care as described in a broader body of information, The report from Ontario s recent engagement process Advancing High Quality, High Value Hospice Palliative Care in Ontario (1), The System Design Framework for HPC in Ontario (18) Key common elements/components which have been identified as being the most important to enhance HPC service delivery (22) The Canadian Hospice Palliative Care (CHPCA) Model to Guide HPC (19). Cancer Care Ontario s Report on Regional Models of Care for Palliative Caner Care (20) The review process for this Part Three examines Models of Care for hospice palliative care in Ontario, at a sector specific level. This examination is descriptive in nature and iii

8 provides examples of how specific sectors describe and fulfill the core components of the multidimensional sector specific model of care. For each 24/7 care setting the description provides: Background and context for palliative care in this sector, Description of most the common elements of current models of Palliative Care service delivery in Ontario for this sector, (using the listing of core elements of sector specific models of HPC as presented in Part One). Summary chart for each sector Reflections on the future role of this sector/service in HPC provision in Ontario. A number of other key HPC Services are discussed and for each the following is explored: Background and Context Typical Models of Palliative Care Role of this Service in Future HPC System Outcomes and Summary Outcomes from this Part Three review were positive in terms of specific aspects of readiness for next steps in the evolution of HPC in Ontario at the sector specific level, including the following: 1. Examples of HPC excellence within each care setting / service Within each of the care settings (24/7 care settings) examined, examples of excellence in terms of HPC programming are evident. Within Ontario there are acute care facilities and complex continuing care facilities with HPC programs that demonstrate all the core components. Likewise there are communities where HPC in the home is well developed. A number of longterm care homes (LTCHs) have HPC as a focus and have made great strides in advancing care for their dying patients. Residential hospices show many examples of excellence in HPC provision. Regional Cancer Centres and their host hospitals have developed robust HPC programs in a number of regions. Similarly within the other HPC services examined, much excellent work is evident. Palliative pain and symptom management consultants, visiting hospice programs, primary care providers and many other services show excellent HPC programming. These well-developed programs can all serve as examples for others within their own care settings / services. 2. Potential for cross sector capacity building There are a number of examples of sectors with HPC as their core business, which demonstrate fulsome development of all core elements. These sectors and services could help serve as capacity builders for other sectors. iv

9 3. HPC expertise in nearly every care setting Almost every hospital, every long term care home, every Community Care Access Centre (CCAC) and every community service provider agency (CSPA), has some available HPC expertise (either internally or accessible from outside sources) 1. Key HPC leaders and clinicians are identified in many care settings and services. Additionally each care setting has some awareness of the potentially positive role of HPC for their patients/clients. Few care settings will be starting completely from scratch. 4. Some investments in HPC have already been made Almost all LHIN regions have made some investment in HPC. Identified service gaps are being filled, particularly as it relates to enhancing HPC for patients in their own homes. 5. Participation in cross sector communication / planning / collaboration. Across the province, stakeholders from all care setting and services are already gathered and are actively communicating at collaborative tables. Much cross sector planning has taken place 6. Presence of related expertise in many sectors that could be segued into HPC expertise While it may not be specifically focused on HPC similar expertise is available in many care settings. For example: Available membership for interprofessional teams Most acute care and complex continuing care facilities and CCACs have access to full interdisciplinary teams. LTCHs have access to spiritual care providers, dietician, physiotherapists etc. These professionals may not yet have specific training in HPC, but are available and could be mobilized to be part of a HPC team. Well-developed philosophy of team Many care settings/services already have well-functioning teams (e.g. Rehabilitation teams). While these teams may not currently serve a HPC population they will have developed skill sets in terms of collaborative care approaches. Well-developed project management skills All of these sectors have planned and implemented many projects and new programs. 7. Some Experience with Cross Sector Projects/Initiatives Almost every care setting/service has some experience with cross sector projects/initiatives related to HPC. From a provincial perspective examples specifically related to HPC include: the Ontario Cancer Symptom Management Collaborative (OCSMP), roll out of Cancer Care Ontario s Symptom Management Guides and Collaborative Care Path, 1 Note Residential Hospices are excluded from this list as it is noted that they possess considerable HPC expertise in each of their facilities (HPC is their core business). v

10 the Integrated Client Care Project (ICCP) currently being piloted in several regions and seeking to engage cross sector partners. At a regional and local level significant cross sector HPC work is evident in terms of: defining right patient, right place, right time elements (i.e. criteria of each care setting etc., advancing use of common tools) cross sector HPC education, cross sector planning for the system, cross sector patient specific rounds (in a few regions) Additionally much knowledge transfer about the basics of HPC has already occurred. There are care providers and leaders in every sector who have already agreed that the new model is the right model and have worked together to produce system level and sector level planning documents that support these key concepts. Certainly gaps in service provision and in practical application of concepts and models of care are evident. This Part Three of the review reiterates the need for stronger linkages between/among sector and the need to continue to promote the creation of HPC access to patients in every care setting where patients die. As each care setting and service continues to enhance its HPC provision many synergies between care settings and services will be realized. vi

11 Discussion Paper February 2012 Multidimensional Models of Hospice Palliative Care (HPC) in Ontario Part Three Sector Specific Models of HPC SECTION 1 - Overview Purpose This discussion paper reviews models of care in Hospice Palliative Care (HPC) in Ontario. It aims to provide insight into our state of readiness for the next steps in evolving to a new model of care. This Part Three of the discussion paper focuses on the sector-specific level. It uses the multidimensional sector-specific model of HPC described in Part One to compare our current state with our aspirational model of care as described in the report from Ontario s recent engagement process Advancing High Quality, High Value Hospice Palliative Care in Ontario (16). The multidimensional sector-specific model checklist is used as a practical proxy for the narrative and diagrammatic descriptions of our aspirational model. Outcomes of this Part Three review provide practical specificity in determining where we are between the extremes of the current model and proposed new model Current Model: Individuals with advanced chronic disease(s) or complex care needs receive care that is reactive, targeted, diseasefocused, centering on curative treatment, and delivered by multiple, siloed, individual providers in distinct, acute episodes. (1) Practical Specificity re. Sector readiness Proposed New Model: Adults and children with advanced or EOL chronic disease(s) and their informal support network will receive care and support that is proactive, holistic, person and family-focused, centering on quality of life and symptom management issues, and delivered by a virtually integrated inter-professional team in a coordinated, continually-updated care plan, that encompasses all care settings in which the client receives care. (1) - 1 -

12 This discussion takes place in three parts: Part One - Presents a practical, check list / template, with core elements to use in describing and creating HPC models of care at a regional level and a sector specific level.(see previous discussion paper Part One for details) Part Two and Part Three Expand upon each of these core elements and apply these checklists / templates to review current status of HPC models of care at a regional level and at a sector specific level (This paper is Part Three sector specific level ; see previous discussion paper Part Two for LHIN level details) By reviewing current status in this systematic way insight is gained into where we need to focus attention at both the regional and sector specific levels. Information Sources and Review Process Information sources This discussion paper pulls together numerous information sources, examining and recollating that work within the context of models of HPC service delivery. Sources of information which are reexamined here include the following: LHIN-specific HPC reports, documents, presentations, websites from across Ontario. Each source was reviewed for reference to models of HPC (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17). LHIN-specific survey responses submitted by each Hospice Palliative Care/ End of Life Care Network in May 2009 for inclusion in Provincial Inventory (21) Individual and collective responses to a survey distributed in February 2010 to participants of the June 23 rd 2009 Strategy Development Workshop Improving the Quality of Hospice Palliative Care across Ontario. These responses were collated by a working group of the Provincial End of Life Care Network (PEOLCN) and presented to the Quality Hospice Palliative Care Coalition of Ontario (QHPCCO). (22) LHIN-specific survey responses submitted by each LHIN office in the fall of 2011 as foundational information for the Ontario Palliative Care Engagement Strategy. Minutes and discussion notes from Provincial End-of-Life Care Network (PEOLCN) and Quality Hospice Palliative Care Coalition of Ontario (QHPCCO) meetings. Sector specific / organization specific websites and reports/documents related to HPC Outcomes from discussions with key informants The outcomes from the above review are referenced against descriptions of models of care as articulated in a broader body of information including: a recent report released by the World Health Organization (23), a report from Cancer Care Ontario (CCO) (20) which makes specific recommendations regarding regional models of care and the organization and delivery of Palliative Cancer Care in Ontario, Canadian Hospice Palliative Care (CHPCA) Model to Guide Hospice Palliative Care (19) Selected articles, summary reviews and reports

13 The report from Ontario s recent engagement process Advancing High Quality, High Value Hospice Palliative Care in Ontario (1) The System Design Framework for HPC in Ontario (18) Key common elements/components which have been identified as being the most important to enhance HPC service delivery (22) Review process The review process for this Part Three examines models of care for hospice palliative care in Ontario, at a sector specific level. This examination is descriptive in nature and provides examples of how specific sectors describe and fulfill the core components of the multidimensional sector specific model of care. For each 24/7 care setting the description provides: Background and context for palliative care in this sector, Description of most common elements of current models of Palliative Care service delivery in Ontario for this sector, (using the listing of elements cited above in Table 1, as part of a comprehensive model of care). Summary chart for each sector Reflections on the future role of this sector/service in HPC provision in Ontario. A number of other key HPC Services are also included and for each the following is explored: Background and Context Typical Models of Palliative Care Role of this Service in Future HPC System Why examine models of care by sectors? This section examines models of care for hospice palliative care in Ontario, by sector. Palliative care is required and provided in virtually all care settings. Health and social care in Ontario is delivered by independent sectors and by independent service providers, each with its own board of directors, individual mandate, operational imperatives and strategic directions. (1) If we are to make changes in the system of Palliative Care we must engage specific sectors who have the operational responsibility for implementing changes within their individual care settings. Ontario s System Design Framework for HPC states: If we are seeking to develop a whole system attention must be given to key elements of service delivery within each of the component parts. The system as a whole is only as strong as the weakest of its component parts. The concept of integration presupposes the presence of several functioning independent programs linking across sectors. We cannot link to something that does not exist. Thus we must have some basic understanding of (and some way to define) what constitutes a HPC program within each sector/setting (18)

14 In the report from Ontario s recent engagement process Advancing High Quality, High Value Hospice Palliative Care in Ontario (1) the importance of functioning programs within specific care settings is reiterated: We note that building an extended inter-professional team for each client will be greatly facilitated to the extent that dedicated, formal inter-professional primary chronic disease management teams and specialized palliative care consultation teams are already available within that community or care setting. Where teams exist, many of the connected providers will already have established team protocols, clear roles, and trusting relationships with each other. (1) The report Advancing High Quality, High Value Hospice Palliative Care in Ontario (1) lists sector specific next steps. Elements of Sector Specific Models of Palliative Care in Ontario Table 1 below lists key elements most frequently cited at the sector level when describing models of HPC. Descriptions under each heading are typically more granular than the regional descriptions and are often captured in facility specific policies and procedures rather than in regional descriptions. Table 1 Summary of Key Elements of a Comprehensive Description of a Model of HPC at the SECTOR-SPECIFIC LEVEL in Ontario A comprehensive Model of Care at a sector-specific level may include the following elements: 1. Vision/values/principles/philosophy & evidence of strategic planning for HPC 2. How this particular sector typically describes its model of care for HPC service delivery (may include comments on configuration of beds, staffing types/levels, funding etc.) 3. Description of how specialist level expertise is accessed (including a listing of professionals involved, funding/service agreements etc.) 4. Explanation of the relationship between primary care and specialist level care (e.g. consultation only, shared care etc.) 5. Information about access to HPC in non-business hours (24/7 access) 6. Admission criteria/referral processes (including description of population served and population not served ) 7. How / what education about HPC is delivered 8. Key Organizational contact 9. Interdisciplinary expertise 10. Linkages with partners 11. Reporting, evaluation, CQI and data accountability 12. Relevant accreditation standards/ best practice guideline and awareness of the CHPCA Model to Guide Hospice Palliative Care - 4 -

15 SECTION 2 - Acute Care (Including HPC Tertiary Care) Background and Context When examining the palliative care system, it is important to understand the acute care sector of palliative care because acute care is a reference point for the system as a whole. One of the strategies of the MOHLTC EOL strategy (2005/06) was to shift care of the dying from acute settings to alternative appropriate settings of the patient s choice. Reducing dependence on acute care is one of the outcomes cited in the majority of initiatives related to enhancing HPC in Ontario. Typically indicators, which are used to measure palliative care improvements within the system as a whole, relate to decreased reliance on the acute care sector. For example Cancer Care Ontario indicators for end-of-life care have included: A measure of decrease in percentage of deaths in acute care. A measure of decrease in the proportion of cancer patients that visited the emergency department during last 2 weeks of life, A measure of decrease in length of stay in acute care for last 6 months of life for patients who died of cancer in Ontario This referencing is not inappropriate since acute care costs are the highest in the system and typically patients report a preference not to be in an acute care facility. Therefore it is important to examine models of HPC in acute care. (3). Description of Core Elements of Acute Care Models of HPC The summary below is drawn from the review of sources of information cited above Vision/Values/Principles/Philosophy related to HPC Frequently acute care settings show no articulated value/principle statement for hospice palliative care per se. Almost universally, there are articulated statements for the organization as a whole, but these may not extend to each program within the acute care setting. Specific statements are more likely to exist where there is a formalized program in place, either dedicated beds or a formal consultation team. In cases where these statements are articulated they are typically in line with the CHPCA principles, values etc. How do Acute Care facilities typically describe their model of care for HPC service delivery? A number of Ontario s acute care settings show no defined model of HPC delivery. For the organizations that do define their acute care HPC model the following categories of description are most common: - 5 -

16 a) Bed alignment: o Dedicated unit / beds / stand-alone unit where specialized staff care exclusively for patients requiring palliative care and physical amenities may be enhanced (e.g. sleeping area for family members, facility for family to do minor food prep etc.) o Integrated unit / integrated beds where a palliative care unit can occupy a portion of a larger unit, dually trained staff can cross-cover and beds can swing from palliative care to other uses as needed o Scattered beds where room amenities are enhanced (e.g. private room with cot for family member) o No palliative care beds per se. Palliative patients integrated with medical/surgical/icu patients as beds are available. (3) b) Access to expertise and type of care sharing between specialist and primary care: o Palliative Care Team o Palliative Care Consultation Physician(s) o Palliative Care Nurse expert o Palliative Care Expert allied health (E.g. Social Work etc.) o No identified HPC expertise Typical types of care sharing between primary care and specialist level care are described below. (18) c) One of the above descriptions of bed alignment combined with a description of access to expertise (this description may include a comment about level of specialist level training of nurses) Description of how specialist level expertise is accessed (including a listing of professionals involved) If the acute care facility has dedicated units/ dedicated beds typically these beds are staffed by professionals RNs, RPNs etc. with a level of HPC expertise beyond the primary care level. Usually these dedicated units/beds have a defined process for accessing Physician expertise and HPC expertise from other professionals. Where no dedicated unit/beds are defined, specialist level expertise is accessed from; 1) Physician or team of physicians and/or 2) Nurse expert and/or 3) Team with a mix of disciplines. 4) External source (community team, hospice team) if no internal expertise exists. A number of Acute Care facilities show no defined method of accessing HPC expertise

17 Explanation of the relationship between primary care and specialist level care (e.g. consultation only, shared care etc.) In cases where access to specialist level care is defined, the relationship between specialist and primary care typically falls within one of the following categories: Physician specialist: 1) Consultation only 2) Consultation and episodic follow-up care 3) Consultation and ongoing shared care 4) Specialist physician(s) assumes all care of patient (this most often occurs if admittance to a dedicated unit is under the purview of one physician or set of physicians) Nurse and/or other non-physician members of the team 1) Consultation to others of same profession 2) Consultation to members of different professions (e.g. HPC nurse specialist may be asked by primary care physician to provide recommendations for care) 3) Consultation and delivery of some or all of the care (e.g. nurse expert may assume role of primary communicator with the family re. DNR; expert social worker may assume the ongoing care for family/patient or may assist a non-specialist level social worker with care). Access to 24/7 specialist Some larger centres have a roster of HPC specialist level on call physicians/team members. Hospitals with specialized beds have access to specialist level nursing round the clock. Admission criteria / referral processes - How is this typically described? Typically descriptions of admission criteria or referral processes fall into one of the categories below: 1) Clearly defined admission criteria/referral processes to HPC when there is: dedicated unit (or dedicated beds), specific palliative care team specific palliative care nurse expert. 2) Discretionary referral processes from primary care physician to specialist physician, 3) Palliative patients within hospital are retrospectively defined as those patients who are coded Z51.5 4) No criteria or processes - 7 -

18 How / what education about HPC is delivered Typical educational offerings related to HPC in acute care include: education to prepare for College of Nurses Association (can) Palliative Care certification; Learning Essentials Approach to Palliative (LEAP), Fundamentals, Comprehensive Advanced Palliative Care Education (CAPCE), Advanced Hospice Palliative Care Education (AHPCE), In house programs etc. Key Organizational contact Organizational contacts specifically for HPC may not be named. When these contacts are named they range in roles. Access to Interdisciplinary expertise Access to interdisciplinary expertise may be: 1) Part of specialist HPC team social work, spiritual care, supportive care team 2) Accessed from larger complement of allied health and other professionals within the acute care setting Linkages with partners Many acute Care facilities have a number of processes in place to link their work for HPC patients. Processes to link with other sectors may include: Cross-sector patient specific rounds, Cross-sector education Participation in/leadership at EOLC/HPC Network tables Initiation of cross sector patient flow pathways Reporting, evaluation, CQI and data accountability Acute care palliative care volumes are reported via DAD Z Additionally there may be manual tracking of access to expertise tracked internally. Quality data specific to the HPC program may be collected and reported internally. Some regions have established reporting opportunities to the LHIN/EOLCN. Relevant accreditation standards/ best practice guidelines/chpca model Most hospitals are accredited via Accreditation Canada using the general standards. Most acute care facilities do not use the specific Palliative Care Standards even if they have a dedicated unit. A few acute care hospitals explicitly reference CHPCA. Host hospitals to Cancer programs may reference CCO best practice guidelines and common tools (e.g. ESAS and PPS). Some other acute care facilities have - 8 -

19 also explicitly embraced the use of standardized assessment tools relative to HPC (e.g. ESAS and PPS) and are using the CCO Symptom Management Guides. Additional considerations -Tertiary Care Units/Beds There are very few HPC tertiary care services identified in Ontario. Fraser Health describes the role of a tertiary care unit as follows: A tertiary HPC (hospice palliative care) unit (THPCU) provides specialized, skilled assessment and intervention in a supportive acute care environment in order to stabilize patients so they may return home or go to a hospice or residential care setting (24) In regions with defined tertiary level palliative care in acute care hospitals, this care typically is provided on a dedicated unit with: o at least 10 beds clustered o access to a broad range of acute care services including: critical care operating rooms radiology and laboratories oncology anesthesia (24) In December 2009 Cancer Care Ontario s Provincial Palliative Care Program released a report titled Regional Models of Care for Palliative Cancer Care: Recommendations for the Organization and Delivery of Palliative Cancer Care in Ontario with 9 recommendations including: All regional cancer programs should offer a tertiary level of expertise to maximize access to specialist palliative care services throughout the cancer centre, hospital and the region. (20) It is unclear as to the degree of implementation of this recommendation across Ontario. Summary table Table 2 below gives a summary of Acute Care description of HPC models

20 Key Element Values/principles/ etc. Description of Model of Care How model of care is most typically described within this sector? Access to specialist level expertise Who is accessed Relationship between primary and specialist care: Physician Relationship between primary and specialist care: nurse and/or non-physician members of the team Table 2 - Models of Hospice Palliative Care Delivery in Ontario Summary Table by Sector Sector: ACUTE CARE - HOSPITAL Description If values/principles/vision is articulated usually in line with CHPCA; frequently not articulated for HPC. 1) Bed alignment: o Dedicated unit / Dedicated beds/stand-alone unit o Integrated unit / Integrated beds o Scattered beds (with or without comment of amenities in room ) o No dedicated beds 2) Access to expertise: o Palliative Care Consultation Team o Palliative Care Consultation Physician(s) o Palliative Care Nurse expert 3) The above description of bed alignment combined with a description of access to expertise (this description may include a comment about level of specialist level training of Nurses etc.) 1)Physician or team of physicians 2) Nurse expert 3) Team 4) No specialist level expertise defined 5) No in house expertise specialist level expertise accessed from external source 1) Consultation only 2) Consultation and episodic follow-up care 3) Consultation and ongoing shared care 4) Expert physician(s) assumes all care of patient (this most often occurs if admittance to a dedicated unit is under the purview of one physician or set of physicians) 1) Consultation to others of same profession 2) Consultation to members of different professions (e.g. HPC nurse specialist may be asked by primary care physician to provide recommendations for care) 3) Consultation and delivery of some or all of the care (e.g. Nurse expert may assume role of primary communicator with the family re. DNR; Expert social worker may assume the ongoing care for family/patient or may assist a non-expert social worker with care) Access to 24/7 specialist Admission criteria / referral processes How is this typically described? Education re. HPC Organizational contact is identified Access to Interdisciplinary expertise Linkages with partners Reporting, evaluation, CQI & data accountability Relevant accreditation standards/ best practice guidelines/chpca model Other Tertiary care? Some larger centres have a roster of HPC specialist level on call physicians/team members. Hospitals with specialized beds have access to specialist level nursing round the clock. 1) Clearly defined admission criteria/referral processes when there are: dedicated beds/unit/, specific Palliative Care team specific Palliative Care Nurse expert. 2) Discretionary referral processes from primary care physician to specialist physician, 3) Palliative patients within hospital are retrospectively defined as those patients who are coded Z51.5 4) No criteria or processes CNA Palliative Care certification; LEAP, Fundamentals, CAPCE, AHPCE, in house expertise etc.- 1)Physician 2) Administrator/Manager 3) Expert HPC Clinician 4) No one identified as HPC contact 1) Part of specialist team social work, spiritual care, supportive care team 2) Accessed from larger complement of Allied Health and other professionals within the acute care setting Processes to link with other sectors may include: Cross sector rounds patient specific rounds, Cross sector education Participation in/leadership at EOLC/HPC Network tables Initiation of cross sector pathways Volumes reported via DAD Z 51.5; manual tracking of access to expertise sometimes tracked internally. Quality data sometimes collected and reported internally. Some regions have established reporting opportunities to the LHIN/EOLCN Most hospitals are accredited via Accreditation Canada general standard. Most acute care facilities do not use the specific Palliative Care Accreditation standards even if they have a dedicated unit. A few facilities/units explicitly reference CHPCA. Host hospitals to Cancer programs may reference CCO best practice guidelines Some use ESAS, PPS & CCO Symptom Management Guides. Rarely do Acute Care facilities mention their role as HPC Tertiary centres

21 Future System Role of Acute Care in Palliative Care Service Delivery Acute Care continues to be an important component of palliative care service provision now and in the future. Acute care involvement with the patient and family requiring palliative care will typically occur at the following junctures on the journey: Diagnosis / prognosis- Frequently patients are in acute care when they receive the news of a terminal diagnosis and prognosis. During the course of palliative care Patients may need to receive treatment for an acute medical or surgical condition or for symptom control. At end-of-life - Across Canada, over half of deaths occur in hospital. With increased services in the community it is anticipated that a number of these patients will be supported to live their last days in a non-acute setting. However some patients will continue to die in acute care due to a number of legitimate factors including the need for services and interventions not available in other settings. Community providers, patients and families need to know that if/when a crisis arises and care needs exceed what can be offered in the current setting, there are acute care palliative care services available. This assurance helps prevent admissions which are motivated by the fear of what if. Additionally a HPC program in the acute care facility will help facilitate discharge back to the community and will help reduce prolongation of treatments which may not enhance quality of life. (3) Preferred Model of Care and Comparative Cost of typical models There are many indications of overall cost benefit of having a palliative care program in acute care versus having no palliative care program. Curative treatments are more expensive than palliative care and may be unnecessarily prolonged if no palliative services are available. Algorithms have been proposed to calculate potential savings. (25) An American study of eight very different hospitals demonstrated significant savings: hospitals saved from $279 to $374 per day on patients in palliative care programs, hospitals saved from $1700 to $4900 on each admission of a palliative care patient, savings included significant reductions in pharmacy, laboratory and intensive care costs. This means a savings of more than $1.3 million for a 300 bed community hospital (25) While it is well documented that having a HPC program within acute care is financially beneficial as compared to having no HPC program, it is not possible to compare which model of palliative care service delivery in hospital is cheapest. There is no available Canadian based cost comparison of models of inpatient palliative care. While a dedicated unit is easy to cost out, other models have HPC patients dispersed on various units and it is difficult to determine costs for HPC patients as distinct from other patients on the unit

22 Which model of inpatient care is best practice? Much debate has occurred over which model of care is most effective and most cost efficient. It is frequently argued that best practice is a dedicated unit but it is often assumed that this model is more expensive. Due to case costing ambiguities (described above), it is difficult to accurately compare costs of a dedicated unit with other models. The Canadian Hospice Palliative Care Association (CHPCA) states, While a specialized environment can be created as needed in the patient s environment, it is frequently more efficient.to have a number of beds in one location. (19) The best configuration of the Palliative Care Beds at each Acute Care site is a matter for each facility to evaluate. What is most important is that each facility acknowledges that patients requiring Palliative Care are in its facility and that some model of palliative care delivery needs to be developed to effectively and efficiently address these patients care needs. Recommended Next Steps for Acute Care/ Alignment with New Model Next Steps Development of tertiary care and emergency department avoidance -Few Tertiary Hospice Palliative Care Units (THPCU) are identified across Ontario..Acute care facilities across Ontario have an opportunity to fulfill the role of a tertiary hospice palliative care unit regardless of their current model of care. Most of the interventions required of a tertiary care centre are already conducted within the acute care facilities what is typically lacking is the acknowledgment that these interventions are for palliative intent - to control pain and other symptoms- rather than to cure the underlying condition. It is expected that by articulating a model of care and by explicitly embracing a tertiary care role, increased awareness/expertise will be developed thereby enhancing identification of patients requiring Palliative Care. (3) The emergency department currently is the most common hospital entry point for patients who require acute care palliative care. Processes should be developed to bypass the emergency department and expedite care and discharge. (3) Development of / Identification of expertise- CHPCA states interdisciplinary teams of secondary hospice palliative care experts must be readily accessible in every setting where patient and families receive care. Each acute care facility should develop and identify such expertise. These next steps align with those identified for acute care in the report from Ontario s recent engagement process Advancing High Quality, High Value Hospice Palliative Care in Ontario (16)

23 SECTION 3 - Complex Continuing Care Background and Context Complex continuing care (CCC) facilities provide continuing and specialized services to medically complex patients, who usually have multiple health problems and/ or functional impairments. There is a variety in the types of services provided, which includes palliative and end-of-life care; and also support to families with respite care needs. (3) CCC beds may be in a standalone CCC facility or may be co-located with acute care beds or LTCH beds. Description of Core Elements of Complex Continuing Care Models of HPC Same as Acute Care Descriptions of most of the core elements in complex continuing care are similar to those described above for acute care. Descriptions that are unique to CCC are cited below. Admission criteria / referral processes - How is this typically described? 1) Clearly defined admission criteria/referral processes to HPC when there is: dedicated unit (or dedicated beds), specific Palliative Care team specific Palliative Care Nurse expert. 2) Discretionary referral processes from primary care physician to specialist physician, 3) No criteria or processes Reporting, evaluation, CQI and data accountability CCC patients are coded separately from acute care patients. An extensive data set is available relating to CCC patients in Ontario. However there are few available published studies or reports that specifically describe and/or compare palliative care service delivery in CCC facilities across Ontario. (3) There may be manual tracking of access to expertise recorded/reported internally. Quality data specific to the HPC program may be collected and reported internally. Some regions have established reporting opportunities to the LHIN/EOLCN. Relevant accreditation standards/ best practice guidelines/chpca model Many hospitals are accredited via Accreditation Canada using the general standards. Most CCC facilities do not use the specific palliative care standards

24 even if they have a dedicated unit. A few CCC facilities explicitly reference CHPCA. Some CCC facilities have explicitly embraced the use of standardized assessment tools relative to HPC (e.g. ESAS and PPS) and are using the CCO Symptom Management Guides. Future System Role of Complex Continuing Care in Palliative Care Service Delivery An opportunity exists to enhance the volume and intensity of HPC services in CCC facilities. Further opportunities may exist for direct admissions to CCC beds from the community, (although occupancy levels near to 100% may make this difficult). This role is consistent with the intent of next steps as articulated in the report from Ontario s recent engagement process Advancing High Quality, High Value Hospice Palliative Care in Ontario (1). Summary table Table 3 below gives a summary of HPC services in CCC beds

25 Table 3 - Models of Hospice Palliative Care Delivery in Ontario Summary Table by Sector Sector: COMPLEX CONTINUING CARE- HOSPITAL Key Element within Description model of care: Vision, values, principles, philosophy Rarely is there articulation of values/principles/vision that is specific to HPC. If it is articulated usually in line with CHPCA. Description of Model of Care 1) Bed alignment: o Dedicated unit / Dedicated beds/stand-alone unit o Integrated unit / Integrated beds o Scattered beds (with or without comment of amenities in room ) How is model of care 2) Access to expertise: typically described o Palliative Care Consultation Team within this sector? o Palliative Care Consultation Physician(s) o Palliative Care Nurse expert 3) The above description of bed alignment combined with a description of access to expertise (this description may include a comment about level of specialist level training of Nurses) Access to specialist level expertise Who is accessed? 1)Physician or team of physicians 2) Nurse expert 3) Team 4) No specialist level expertise available Relationship between primary and specialist care: Physician Relationship between primary and specialist care: nurse and/or nonphysician members of the team Access to 24/7 specialist Admission criteria / referral processes How is this typically described? Education re. HPC Organizational contact is identified Access to Interdisciplinary expertise Linkages with partners Reporting, evaluation, CQI and data accountability Relevant accreditation standards/ best practice guidelines/chpca model 5) No in house expertise specialist level expertise accessed from external source 1) Consultation only 2) Consultation and episodic follow-up care 3) Consultation and ongoing shared care 4) Expert physician(s) assumes all care of patient (this most often occurs if admittance to a dedicated unit is under the purview of one physician or set of physicians) 1) Consultation to others of same profession 2) Consultation to members of different professions (e.g. HPC nurse specialist may be asked by primary care physician to provide recommendations for care) 3) Consultation and delivery of some or all of the care (e.g. Nurse expert may assume role of primary communicator with the family re. DNR; Expert social worker may assume the ongoing care for family/patient or may assist a non-expert social worker with care) Some larger centres have a roster of HPC specialist level on call physicians/team members. Hospitals with specialized beds have access to specialist level nursing round the clock 1) Clearly defined admission criteria/referral processes when there are: dedicated beds/unit/, specific Palliative Care team specific Palliative Care Nurse expert. 2) Discretionary referral processes from primary care physician to specialist physician, 2) No criteria or processes CNA Palliative Care certification; LEAP, Fundamentals, CAPCE, AHPCE etc.- 1)Physician 2) Administrator/Manager 3) Expert HPC Clinician 4) No one identified as HPC contact 1) Part of specialist team social work, spiritual care, supportive care team 2) Accessed from larger complement of Allied Health and other professionals within the CCC setting Processes to link with other sectors may include: Cross sector rounds patient specific rounds, Cross sector education Participation in/leadership at EOLC/HPC Network tables Initiation of cross sector pathways RAI May be internal tracking of access to expert team as well as quality data. Some regions have established reporting opportunities to the LHIN/EOLCN. Most hospitals are accredited via Accreditation Canada general standard. Most CCC facilities do not use the specific Palliative Care Standards even if they have a dedicated unit. A few CCC facilities explicitly reference CHPCA & a few use ESAS/PPS/CCO Symptom Guides