Provincial Hospice Palliative Care Home Based Nurse Practitioner Program: Supporting Patients to Live with Dignity and Comfort at Home

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1 Provincial Hospice Palliative Care Home Based Nurse Practitioner Program: Supporting Patients to Live with Dignity and Comfort at Home Janet McMullan, RN, BScN, MN, Clinical Program Lead, OACCAC James Mastin, BSc (BMED), BScN, MSc, PHCNP, HPC Nurse Practitioner, TC CCAC Heather Elliott, RN, MSN, CHPCN(C), APN - Hospice Palliative Care, WW CCAC Heebah Sultan, BHSc, MPH, Health Data Analyst, Information Management, OACCAC Outstanding care every person, every day

2 Agenda Objective Learn about the CCAC Hospice Palliative Care Nurse Practitioner program and the difference these nurses are making to support patients to live with dignity and comfort at home. Agenda 1. Provide background for the Provincial Hospice Palliative Care Nurse Practitioner Program. 2. Learn about the lessons learned through the lens of two implementation experiences from Toronto Central CCAC and Waterloo Wellington CCAC. 3. Introduce the recently developed provincially standardized performance measurement processes that are being used to capture key indicators. 2

3 About CCACs in Ontario Ontario is divided into 14 Community Care Access Centres (CCAC). CCACs provide a single point of access to a wide range of home and community services, enabling people to have the specialized blend of the health services they need, when they need it. In 2013/14, CCACs helped over: 700,000 people receive care in their homes and communities, 349,000 seniors, enabling them to stay in their homes independently 27,000 people through their end of life experience 4,000 people be discharged from hospital per week. 3

4

5 CCACs & Hospice Palliative Care CCACs have a long tradition in supporting patients with palliative care and end of life care needs. Specialized HPC Services, including: Specialized HPC Care Coordinators and teams that link with HPC resources beyond CCACs Collaborative care planning based on the patient s goals, wishes, and values Use of standardized HPC assessment tools Access to grief loss and bereavement services throughout the care trajectory 5

6 Advancing High Quality, High Value Palliative Care in Ontario Declaration of Partnership & Shared Priorities. HPC NP practice supports patients across the chronic disease continuum model. Declaration of Partnership and Commitment to Action December, 2011, adapted from CHPCA 2002

7 HPC NP Program Provincial HPC NP Goal Working within an inter-professional Team, the NP acts as a bridge to support hospice palliative care (HPC) patients who have life-limiting illness by: Enhancing quality of HPC Reduce hospitalization and avoidable emergency department visits Supporting patients in dying in their place of choice Strengthening capacity of Primary Care Providers to provide HPC Provincial HPC NP Target Population Adults and Children with hospice palliative care needs who can be identified using three triggers: The Surprise Question would you be surprised if the patient would die within 12 months? Choice Need patient makes a choice for comfort care only Clinical Indicators patient with cancer, organ failure, elderly with frailty, stroke, dementia Key Performance Measures for Success Improved pain and symptom management Dying at home or in the patient s place of choice Reduced avoidable emergency department visits and re-hospitalization Improved patient/caregiver experience 7

8 HPC NP Role Collaborates with the CCAC Care Coordinator in service planning Provides Direct Clinical Care Establishes effective working relationships through formal partnerships or shared care arrangements with a broad range of primary care providers Builds capacity within the primary care sector in best practice HPC using knowledge transfer approaches, research, and leadership opportunities Works with the primary care providers and the HPC Integrated Team to coordinate access to specialized HPC and, when needed, acute care services Ensures the coordinated exchange of information across primary care, acute care and specialized care providers 8

9 About the HPC NPs Visit Initiatives/hospice-palliative-care-nurse-practitioners See video at the bottom of the page 9

10 Implementation Lessons TC CCAC

11 Current NP Scope of Practice in Ontario Communicating to a patient or a patient s representative, a diagnosis made by the NP identifying a disease or disorder as the cause of the client s symptoms Open prescribing Performing a procedure below the dermis or a mucous membrane Applying or ordering the application of a prescribed form of energy i.e. x-ray, mammogram, and ultrasound Ordering of diagnostic tests i.e. specimen testing Complete medical certificates of death

12 Advanced care planning and discussions surrounding DNR s, POA s and living wills Manage the complex end-of-life medical, and social needs of patients and caregivers Attends to both the patient and family s grief and bereavement, and offers support or referral to interdisciplinary team Manages mostly non-cancer patients suffering from end-stage diseases such as CHF, COPD, dementia and ALS HPC NP Role Supporting the patient in their journey towards death

13 TC CCAC HPC NP Support patients upstream on the illness trajectory and at end of life Manage physical and cognitive symptoms such as pain, nausea/vomiting, dyspnea and delirium management Consultation and shared care with the Palliative Care Team including physicians through Temmy Latner and Dorothy Ley: when NP is out of scope cover after hours when NP not available Future plans for 24/7 coverage by HPC NP s Attend patient and family at time of death to pronounce and sign death certificate

14 Collaborative work with both community and acute care hospitals with chronic/complex and end-of-life patients Part of the interdisciplinary team which consists of a team of Pharmacists, Clinical Nurse Specialists and Nurse Practitioners Provide TC CCAC with a consultative role to support Care Coordinators, Rapid Response Nurses and Tele-Homecare Registered Nurses Referrals come from internal Care Coordinators, Palliative Care Teams, Community Health Centres and acute care hospitals TC CCAC HPC NP s.

15 Implementation Lessons WW CCAC

16 Waterloo-Wellington 16

17 Waterloo-Wellington 17

18 Waterloo-Wellington 18

19 HPC Specialty Education for NPs 19

20 Performance Measurement

21 E-form Development

22 Collaboration with CCACs Developing provincial working groups Standardization of data across all 14 CCACs Incorporating input from each group from each CCAC Provincial support metrics, deployment of e-forms, communication Combining input into e-forms, work on e-forms, business process evolution 22

23 Results Who are our Patients? Over 75 per cent of referrals receiving HPC NP services were 65+ years of age, however patients with a variety of ages receive services. Over half of the patients were female. 3,000 Age Breakdown Gender Breakdown 2,500 2,000 1,500 1,000 Male 46% Female 54% years years 65+ years Please note that data shown in this slide is for 13/14 CCACs. 23

24 Results There are 70 HPC NP positions across the province. Performance Measures Actuals # of HPCNP patient referrals over 3,000 # of HPCNP patient visits - Total over 17,000 Face-to-Face Visits over 12,000 Phone Visits Over 5,000 Approximately 23,000 HPCNP e-forms submitted provincially from April 1, 2014 to March 31,

25 Referral Discharge Disposition Breakdown Place of Death Died in Retirement Home 3% Died in LTCH 1% Died in Other Location 6% Died in Hospital 24% Died at Home 50% Died in Residential Hospice 16% Data on referral discharge dispositions is reported for all referrals discharged who received HPCNP services during the 2014 calendar year. Of the over 2,000 referrals discharged who received HPCNP services, approximately 80% of the referrals died, approximately 12% were admitted to hospitals, and over 8% received some other referral discharge disposition. 25

26 Key Lessons Strategic governance is essential and requires Senior Director leadership and broad engagement of CCACs Investment in resources for planning will result in effective and timely implementation Meaningful connections through face-to-face meetings early the process foster working group cohesiveness to build consistency across programs Early stakeholder engagement is key LHINs, hospitals, primary care providers, pharmacists, CSS Effective Communication Plan is necessary to support consistent community messaging about new programs Education/networking opportunities are important for consistent role development and knowledge translation Technology opportunities need to be leveraged to promote efficiencies and performance measurement 26

27 Outstanding care every person, every day

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