Chronic Care Application of the Cancer Care Ontario Palliative Care Program s Models and Products Dr. José Pereira

Transcription

1 Chronic Care Application of the Cancer Care Ontario Palliative Care Program s Models and Products Dr. José Pereira Provincial Head, Palliative Care, Cancer Care Ontario Medical Chief, Palliative Care Services, Bruyère Continuing Care and The Ottawa Hospital, Ottawa Head & Professor, Division of Palliative Care, University of Ottawa

2 Cancer remains significant source of illness burden In 2007 in Ontario: new cancer cases deaths Some cancers taking on a chronic disease trajectory 2

3 Content 1. The CCO Palliative Care Program 2. Defining Palliative Care 3. Models of Care 4. CCO Mentorship Project & Primary Care Engagement 5. Symptom Assessment & Management 6. Disease Management Pathway & Service Plan 7. Quality Performance Indicators 3

4 CCO Palliative Care Program Palliative Care Integral component of clinical programs Office with support staff Provincial lead & 14 Regional leads Monthly meetings Local regional engagement (cancer centres, Regional Cancer Programs, EOL networks & Regional Palliative Care Programs Close collaboration with: Radiation Oncology leads Medical Oncology leads Primary Care leads 4

5 Defining Palliative Care 5

6 Supportive and Palliative Care Across the Illness Trajectory Treatments to cure or control disease earlier phases Diagnosis made of life-limiting illness Supportive & Palliative Care Illness trajectory Terminal phase (EOL) Death Bereavement care

7 Pts with newly diagnosed metastatic lung cancer RCT: Early palliative care consultation versus standard EOL referral Pts with early palliative care consultation: Less depression Less anxiety Better QOL Temel J, et al. Early Palliative Care for Patients with Metastatic Non Small-Cell Lung Cancer. NEJM 2010; 363:733-42

8 Pts with early palliative care consultation: Received less aggressive treatments Lower health care costs Lived 3 months longer Temel J, et al. Early Palliative Care for Patients with Metastatic Non Small-Cell Lung Cancer. NEJM 2010; 363:733-42

9 CCO: The Cancer Journey (current model) RECOVERY PREVENTION SCREENING DIAGNOSIS TREATMENT PALLIATIVE & END-OF- LIFE CARE 9

10 CCO: The Cancer Journey (emerging approach) RECOVERY PREVENTION SCREENING DIAGNOSIS TREATMENT END-OF-LIFE SUPPORTIVE & PALLIATIVE CARE CARE 10

11 Models of Care 11

12 Levels of Hospice Palliative Care Delivery Tertiary level Secondary level Specialist-levels of hospice palliative care Primary level Palliative Care Australia

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16 CCO: Recommendations for roles contd.

17 CCO: Recommendations for qualifications

18 Primary Care Involvement in Providing Palliative Care in Cancer Care Emerging focus for CCO Palliative Care Program Involvement varies across province Overall, in large urban areas, there appears to be a lack of involvement Notable exceptions 18

19 Primary Care Involvement in Providing Palliative Care: Need to understand & develop strategies Late (& lack of) transfers back to primary & home care Pts perceive they require specialists Oncologists who don t let go Cancer Centre & oncologists G512 billing code Palliative Care Remuneration models (fee for service and inappropriate APPs) that undermine consultation, shared care & education roles PPSMCS RN model (lack of funding & support for MDs) Factors contributing to reduced primary care involvement Home Care Lack of training & comfort? Family Physicians Policy Lack of support for family physician role Call requirements? Opt out of palliative care? Easier to transfer care? Billing codes Funding models Death certificates Drug benefits MD driven rather than pt-driven 19

20 CCO MODELS OF CARE INITIATIVE: Ensuring appropriate human resources and funding models Funding Models Tertiary level Secondary level Fee-for-service model inappropriate Need review of Palliative Care AFP/APP CCO- Oncology AFP serves as model Primary level Current fee-for-service remuneration incentive Palliative Care Australia

21 CCO Mentorship Project Primary Care Engagement strategy MoHLTC funded, administered by CCO Third year Pallium LEAP training & mentorship model Mentors: Interprofessional palliative care teams Mentees: Primary care teams (FHTs, etc), LTC facilities, cancer centres, hospitals, etc Over 14 regions have benefitted For : 8 regions involved 21

22 The Canadian Pallium LEAP Course National Course, primary-level (since 2004) 11 modules, 2-day inter-professional course Standardized courseware /toolkits Peer reviewed Multiple learning methods Theory burst (short interactive lecture) Reflective exercises Large Group Case-based discussions Small Group Case-based discussions Trigger Videos Bring your cases & challenges Practical exercises Pallium Palliative Pocketbook

23 LEAP Course: Overall Mean (SD) Pre and Post-Course Knowledge Quiz Scores by Discipline n Pre Course Mean (SD) Post Course Mean (SD) Effect Size** Discipline Registered Nurse (3.0) 11.8(2.8)* 0.64 Pharmacist (2.8) 12.9(2.2)* 0.71 Physician (2.5) 12.1(2.8)* 0.69 Other (3.0) 12.0(3.1)* 0.68 Total (2.9) 12.1(2.7)* 0.69 * Significant at the 0.05 level ** Cohen s interpretation of effect size: Small= ; Medium= ; Large=

24 Symptom Assessment & Management 24

25 Cancer patients experience many symptoms across the illness trajectory Symptom Intensity & Tumor Stage (Non-hematological cancers) N= 240 Median # of symptoms = 8 per patient No evidence of disease Local disease Regional disease Metastatic disease No. of symptoms 9 (0-24) 7 (0-17) 6 (0-15) 10 (0-25) Moderate to severe symptoms 4 (0-14) 3 (0-12) 3 (0-12) 6 (0-20) Chang VT et al. Symptom and Quality of Life Survey of Medical Oncology Patients: A Role for Symptom Assessment. Cancer 2000;88:

26 Symptoms are under-reported by patients unless standardized questionnaire used Far fewer symptoms identified when clinicians relied only on openended questions versus systematic assessment with a scale White C, et al. Now that You Mention it, Doctor... :Symptom Reporting and the Need for Systematic Questioning in a Specialist Palliative Care Unit. J Pall Med 2009; 12(5):

27 Edmonton Symptom Assessment System (ESAS) 27

28 Computerized Symptom Screening 28

29 ISAAC (Interactive Symptom Assessment and Collection) tracks symptoms over time 29

30 Provincial Symptom Burden High prevalence of numerous symptoms in ambulatory cancer population 75% report fatigue 57% report anxiety 53% report pain 49% report shortness of breath 44% report depression 25% report nausea Results based on 224,606 ESAS records for 45,118 patients ( ) from the CCO Symptom Management Database (Barbera et al, Cancer 2010) 30

31 Patients who complete ESAS value this approach to symptom assessment 87% Thought ESAS was important to complete as it helps health care providers know how they are feeling 79% Agreed that their pain and other symptoms have been controlled to a comfortable level 79% Agreed that their providers took into consideration ESAS symptom ratings in developing a care plan Survey of 2,921 patients from 14 Regional Cancer Centres in

32 Computerized symptom self-assessment encourages intervention, improves outcomes Use of patient computerized symptom self-assessment reports by clinicians led to significantly improved patient care and reduced symptom distress in a randomized clinical trial Ruland et al, J Am Med Inform Assoc, 2010 Symptom screening through ISAAC results in further detailed assessment and referrals 42% increase in dyspnea assessment 30% increase in pain assessment Gilbert et al, J Pain and Symp Mgmt, In press Often leading to a reduction in symptom severity 69% of patients experiencing severe pain had scores reduced to mild or moderate level 31% of patients experiencing severe dyspnea had scores reduced to mild or moderate level Gilbert et al, J Pain and Symp Mgmt, In press 32

33 Functional status: The Palliative Performance Scale (PPS)

34 Mean PPS Score Cancer patients seen at Cancer outpatient clinics across Ontario ( ESAS 7,882 PPS Mean age: 65 years Functional decline gradual up to 70% Rapid decline after 50% Time Before Death (in weeks) Seow H et al. JCO 2011;29(9):

35 Evidenced Based Tools to Guide Care 35

36 Symptom management point of care decision support: Apps Named one of nine Best Medical apps by The Medical Post (June

37 Are We Meeting Patients Emotional Needs? 37

38 Disease Management Pathway & Service Plan 38

39 Disease pathway mapping: EOL & Palliative Care 39

40 1. Identify 2. Assess 3. Plan 40

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42 End-of-Life Transition Stable Palliative Triggers or Alerts (PPS based)only FOR PATIENTS WITH CLINICAL SIGNS OF PROGRESSING DISEASE PPS Consider when PPS is Must have been done by the time PPS is 80% 70% 60% 50% 40% 30% 20% PPS: start monitoring at each visit ESAS: start doing at each visit (assess QOL & symptoms with patient) Review illness status: discuss disease progression, quality of life (QOL); pt/family understanding, expectations, goals of care. Introduce Palliation Resuscitation: discuss, advise DNR & complete form (DNRC) Monthly visits: start (to office or home) CCAC Home Care Services: activate Emergency plans: discuss & give instructions on accessing 24/7 support. Avoid calling 911 if possible Options/preference for setting of care: (home or hospice) & document Weekly home visits Prepare for End-of-Life: Prepare family & caregivers: what to expect, signs of imminent death, what to do when person dies. Stop non-essential meds Review route of administration of essential meds (e.g. opioids & delirium meds); order pre-filled syringes for SubQ in case pt unable to swallow Make arrangements for completing death certificate Review again setting of death/care preference Discontinue vital signs PPS: start monitoring at each visit ESAS: start doing at each visit Review illness status: see 60% Resuscitation discussion (see 60% Monthly visits: start (to office or home) CCAC Home Care Services: activate Emergency plans: See 50% Options/preference for setting of care: See 40% Weekly home visits Prepare for End-of-Life:

43 Palliative Care Registries (e.g. FHTs/FHOs/CHC/LTC facilities) considered to be best practice 43

44 Quality Performance Indicators 44

45 Quality Indicators End-of-Life Care Symptom Assessment Patient Experience 45

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51 Conclusions CCO has experience, products and leveraging to contribute to provincial HPC renewal. CCO is open to collaborate with MoHLTC, Ontario College of Family Physicians & HPC Coalition 1. Palliative Care earlier in the illness trajectory 2. Models of Care 3. CCO Mentorship Project & Primary Care Engagement 4. Symptom Assessment & Management 5. Disease Management Pathway & Service Plan 6. Quality Performance Indicators 51