Empowerment and Team Work: a complex symptoms management care model
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1 Empowerment and Team Work: a complex symptoms management care model Vancouver AstraZeneca Septembre 2004 Anne Plante, M.Sc.inf. CSIO, CSISP Centre intégré de lutte contre le cancer de la Montérégie
2 Regional Cancer Centre (Monteregie) Réseau Cancer Montérégie Hôpital Hôpital Charles Charles LeMoyne LeMoyne Réseau Réseau Santé Santé Richelieu- Richelieu- Yamaska Yamaska Hôpital Hôpital Brome- Brome- Missisquoi- Missisquoi- Perkins Perkins Hôtel- Hôtel- Dieu Dieu de de Sorel Sorel Hôpital Hôpital du du Haut- Haut- Richelieu Richelieu Centre Centre Hospitalier Hospitalier Pierre- Pierre- Boucher Boucher Centre Centre Hospitalier Hospitalier Régional Régional du du Suroît Suroît 19 local community centers Centre Centre Hospitalier Hospitalier de de Granby Granby Centre Centre Hospitalier Hospitalier Anna- Anna- Laberge Laberge
3 Task force committee on Cancer Care Quebec strategy for cancer Care (P.Q.L.C.) The philosophy of Monteregie Comprehensive Cancer Care Center (CICM) 9 hospitals /12 nurse navigators
4 Regional committees: Head nurses Psychosocial workers (social workers, psychologists) Oncologists Surgeons Pharmacists Nutritionists Physiotherapists Volunteers Regional oncology training program Evidence based practice Interdisciplinary team work Health promotion : the patient as «Captain of the boat»
5 P.Q.L.C. s objectives prevention early detection quality of life quality of care and support patient satisfaction patient breathing space and adaptation professional satisfaction team stability everyone potential and resources flexibility
6 Flying 101 Team Work 101
7 Model of care: Complex symptom management Diagnosis Oncologist referral to nurse navigator Nurse navitator meets with the patient and his family Assessment Teaching Support Empowerment Referrals (related to practice limits) Related to complex symptoms
8 Model of care: Complex symptom management Nurse navigator presents the complex cases at the interdisciplinary weekly meeting Specific care plan is designed for every patient and family (team coherence and continuity) (unity of action) Every professional is responsible for his/her assessment, teaching, support, referrals, work analysis process: Symptoms Hypothesis Interventions The patient is «The captain of the boat» with his resources and strengths
9 Flying Team Work 102
10 Care plans and speciality referral criteria Criteria are developed for referral to: Nurse navigator Pain management nurse specialist Oncologist Pharmacist Psychologist Social worker Pastoral worker Physiotherapist Nutritionist Psychiatrist Occupational therapist
11 Symptom assessment Patients are asked to complete their ESAS (selfmanagement) Patients are invited to prepare their interview with the oncologist with the help of a check list The oncology clinic nurse discusses the symptoms with every patient (Q.O.L.) He/she makes the appropriate interventions He/she may consult a colleague Work analysis process: - Symptoms - Hypothesis - Interventions If the symptom is complex, a referral is made with a specific description of the request
12 Patient, family centered care Team-Building care strategies Family systems nursing approach Nurse navigator s major role Reflective practice Symptom Hypothesis Interventions
13 Flying Team Work 103
14 CICM CLINIQUE D'HÉMATO-ONCOLOGIE Hôpital Charles-Lemoyne Report ESAS Auto-évaluation des symptômes Système pour l'évaluation des symptômes (ESAS) Symptom Assessment system scale Mettre une barre ci-dessous à l'endroit qui correspond à ce que vous ressentez actuellement Please make mark that best describe how you are feeling 0 10 Pas de douleur/ Douleur maximale/ no pain Worst possible pain 0 10 Pas de fatigue/ fatigue extrême/ Not tired Worst possible tiredness 0 10 Pas de nausées/ nausées maximales/ Not nauseated worst possible nausea 0 10 Pas de dépression/ Dépression extrême/ Not depressed Worst possible depression 0 10 Pas d'anxiété/ Anxiété maximale/ Not anxious Worst possible anxiety 0 10 Pas de somnolence/ Somnolence extrême/ Not drowsy Worst possible drowsiness 0 10 Excellent appétit/ Pas du tout d'appétit/ Excellent appetite/ Worst possible appetite 0 10 Bien-être parfait/ Mal-être le pire possible/ Perfect feeling of well-being Worst feeling of well-being 0 10 Respiration normale/ Essoufflement maximal/ Not short of breath Worst possible shortness 0 10 Autres problèmes/ Others problems ESAS- Système d'edmonton pour l'évaluation des symptômes, Rev. 2/11/99
15 CICM CLINIQUE D'HÉMATO- ONCOLOGIE Hôpital Charles-Lemoyne (Plotting to identify patterns) Système pour l'évaluation des symptômes (ESAS) Symptom Assessment system scale Graphic report date 10 Douleur 8 (Pain) Fatigue 8 (Fatigue) Nausées 8 (Nausea) Dépression 8 (Depression) Anxiété 8 (Anxiety) Somnolence 8 (Sleepiness- 6 drowsiness) Appétit 8 (Appetite) Bien-être 8 (Well being)
16 Patients and families are supported to use their own resources and strengths Teaching sessions are offered: Cancer and nutrition Cancer and sexuality Cancer and family Cancer and young children Cancer and spirituality Cancer and pain Cancer and fatigue Cancer and hope Cancer and emotion
17 Patients and families are supported to use their own resources and strengths Complementary and alternative medicines are offered: Therapeutic group support Art therapy Mental imagery Hypnosis Metastatic group support Nadeau technique
18 Model of care: Complex symptom management Results Planning for safe discharge Discharge from the unit Clinic treatment patient satisfaction doctor satisfaction professional satisfaction Community nurses and psychosocial workers staff absenteeism (continuity of care) patient autonomy and adaptation administrator support Evidence based practice for all disciplines
19 Flying Team Work 104
20 Conclusion A well-defined philosophy Educational Support A new Captain: the Patient A better attitude: everyone is responsible for simple symptoms The overwhelming role of the nurse navigator A better continuity and cooperation
21 Flying 105 Team Work 105
22 Nurse navigators in Monteregie Line Roberge RSRY Lucie Laporte HCLM Sonia Joanette HCLM Rachel Rémillard CHAL Mélanie Fortier CHG Blandine Danis BMP Sylvie Cartier CHPB Louise Leduc CHRS Louise Raymond HHR
23 «Prix Mérites C.Q.L.C.» Recognition award from Ministry of health of Quebec
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