Advancing High Quality & High Value Hospice Palliative Care

Transcription

1 Advancing High Quality & High Value Hospice Palliative Care 1

2 Presentation Overview Background End of Life Care Networks / South West Hospice Palliative Care Network (2004) Provincial Declaration of Partnership and Commitment to Action (2011) From the declaration, the definition of what is Hospice Palliative Care is When should it be considered? Provincial Hospice Palliative Care Structure, Deliverables and Targets South West LHIN Hospice Palliative Care Structure, Goals and Quality Improvement Framework Improvement Opportunities

3 Original Mandate of end-of-life care networks (MOHLTC, 2004) Broad system design Coordination and integration of services at the system level Promotion of service innovations Monitoring and assessment of community needs

4 South West Hospice Palliative Care (HPC) Network Strategic Plan (2010 / 2011): Strategic Planning Priority Identification Setting The Stage for Change Workshops Strategic Plan Access to expert consultation in all communities and settings Small steps, focus, don t spread too thin Define model, replicate Develop common goals across programs Shared communication portal Understanding what each other does Consistent communication with patients and families Based on consistent standards adopted by Network Different intensity of training for generalists and specialists Greater reach of existing programs (e.g. in colleges, university) Funding to match educational requirements Provide a compelling case for investment of time, energy, and resources in HPC Establish a vision that is aspirational but also practical Focus Network s modest resources on work that will yield the greatest results for patient and family care Articulate key changes we wish to make Offer practical change management strategies Develop a group of individuals interested in contributing to projects Raise Awareness about HPC Advance an integrated system of care Enhance Quality of work life for HPC Providers Strengthen the Network s ability to influence change Sustain an infrastructure to support the network s growth 4

5 South West HPC Network Key Milestones (2011 / 2012) A re-established network with a DRAFT Terms of Reference A new website A plan for palliative Nurse Practitioner resources A stakeholder scan of Hospice Palliative Care services in Grey and Bruce Counties An indicator in the Integrated Health Services Plan for the South West LHIN 5

6 South West Hospice Palliative Care Network 6

7 The Declaration of Partnership and Commitment to Action (2011) Organizations and care providers for changing care delivery practices and processes LHINs for regional planning, performance monitoring and establishing shared organization accountability for outcomes Ministry for policy consideration and stewardship 7

8 Overview of Hospice Palliative Care Active total care of patients whose disease is not responsive to curative treatment WHO Incorporates active and compassionate therapies to comfort individuals & families CHPCA, 2002 Where? Required in ALL CARE SETTINGS WHERE PEOPLE DIE (i.e. where people are living their lives). Who provides HPC? Provided by many professions, specialists and primary care. 8

9 When should Hospice Palliative Care be considered? The Role of Hospice Palliative Care During Illness/ Simultaneous Care (from Canadian Hospice Palliative Care Association model) anyone with a life-limiting or life-threatening illness, (even while receiving active treatment) 9

10 When should Hospice Palliative Care be considered? New Model Linked with Chronic Disease: 10

11 Who should receive Hospice Palliative Care? The would you be surprised question: Would you be surprised if this person died within the next year?...if no - appropriate for HPC. Symptoms that require attention?.if yes HPC now. (A palliative approach usually needs to begin earlier than 1 year prior to death with Advance Care Planning etc.) 11

12 Why focus on Palliative Care? Effective 1. Clinical Focus reduced pain and symptoms, burden of care improved quality of life overall reduce burden of survivors 2. System Focus Positive outcomes for system overall related to: Decreased ED visits Admission avoidance Measurable hospital savings through significant reductions in pharmacy, laboratory and intensive care costs 12

13 Vision from the Declaration of Partnership and Commitment to Action (2011) We need to develop a system that. better supports people with life-limiting illnesses and their families; dramatically improves their comfort, dignity and quality of life preceding death; and is based on collaboration and commitment across all care settings, and between families, providers, academics, funders and policy makers, with shared ownership of solutions and actions

14 Six Themes 14

15 Declaration Priority #1: Strengthen Accountability / Introduce Mechanisms for Shared Accountability Clinical Level Cross Sector Accountability Accountability to integrate delivery as part of a virtual team Develop a standard template to ID shared accountability on teams Organizational Level Cross Sector Accountability Regional Level Governance Establish accountability with Regional Network/Program Implement mechanism to ensure organizational accountability so palliative care is provided in each care setting Develop a standard collaboration template to codify organizational accountability to one another Develop a comprehensive integrated HPC program in each LHIN that includes inter-agency accountability ID Palliative Care as a regional priority and mandate minimum standards in all care settings Accountability agreement to ensure that collaboration occurs at all levels of planning and service delivery

16 Declaration Priority #2: Improve Integration and Continuity Across Care Settings Integrated Delivery through teams Provide care through an inter-professional team approach working from a common care plan with a common information sharing mechanism Service Planning for teams standardized delivery across all care settings; expectations in HSP Accountability Agreements Common Processes and Practices Developed and Standardized Clarify expectations for standardized delivery across all care settings Align with CHPCA standards (screening tools, practice guides, best practice tools) Align with CDM initiatives Use Innovative Technology as an Enabler of Integrated Care Delivery Leverage technology solutions that currently exist as enablers for integration and coordination Every care setting/ service, caring for dying patients requires access to Specialist Level Hospice Palliative Care expertise (in addition to Primary Level Providers)

17 Declaration Priority #3: Strengthen Service Capacity and Human Capital in All Care Settings Strengthen Primary Delivery through Access to Secondary and Tertiary Level Expertise Examine ways to strengthen and leverage access to palliative care expertise at all levels (primary, secondary, tertiary) Complete a gap analysis of what currently exists within each area Provide access to Expert Palliative care Determine what resources are needed within each community to ensure access to palliative consult teams Consistent and Standard Education and Competency requirements for all levels of care Skill and expertise in coaching, mentorship and specialized support Operationalize the three Provider Roles in Palliative Care (CPHSA) (primary, secondary, tertiary) Deliver clear communication targeted at new and existing HHR and HSPs to ensure palliative competencies are met Provide Education aimed at three streams Identify coaching and mentorship roles required at each level of care provision Develop competencies for coaching/mentoring Establish a mentoring/coaching program in each interprofessional team

18 Declaration Priority #4: Broaden Access and Increase Timeliness of Access Ensure Early Identification and Access to supports and Care Options More Equitable Access for All Population groups More Equitable Access Across Geographies Align with Chronic disease Continuum Model Integrate with CCAC Population Based Model Earlier care planning to support episodic issues Develop a plan to identify people who are marginalized who would benefit from palliative care services (e.g. First Nations, Street involved or homeless, unattached) Develop an integrated regional plan and model to deliver community rural palliative care building upon local resources Leverage technology to improve access (e.g. OTN,THC, e-shift) Create effective planning and measurement tools Implement agreed upon benchmarks

19 Declaration Priority #5: Strengthen Caregiver Supports Build Client and Caregiver Empowerment and Capacity Self Management Strategies Include client and family in care conferences Access to Services Expand Bereavement services as an integral part of the palliative team Information and Support to Caregivers Make information specific to region accessible to caregivers Examine ways to strengthen and leverage existing on-the ground supports for informal caregivers

20 Declaration Priority #6: Build Public Awareness Engage in Public Dialogue Speak Up Advance Care Planning Open up discussion s about end of life and earlier referrals to Palliative care Develop communication strategies to assist health care providers in truth telling Improve Access to Information Central Hub: Place for information and sharing Customized information for different groups Peer mentorship program for the public

21 Hospice Palliative Care Provincial Steering Committee 21

22 LHINs Recognize need for Immediate Implementation Currently, 50% of all Ontario deaths occur in acute care, which is costly and contrary to Ontarian s preferences to die in other settings of choice Province wide outcome of a minimum 10% shift in deaths that occur in acute care will have an approximate impact of $11 million in savings / cost avoidance (Bending the Health Care Cost, 2010) Impact is further enhanced with a consideration of avoidable hospitalizations, reduced length of stay, province-wide improvements could result in net annual saving / cost avoidance of up to $70 M (ICCP estimates) 22

23 LHINs have agreed to Core Set of Common Deliverables Significant level of variation in current palliative care across the province (delivery models, access, standards, etc.). To resolve this, LHINs have agreed to accomplish the following by March 2015: 1. Establish a regional palliative structure / program / network, with specialized palliative and advanced chronic disease resources coordinated at the regional level 2. Implement a palliative care indicator as part of the MLPA 3. Implement a Palliative Balanced Scorecard 4. Established performance and outcome tracking and feedback at the client, provider and team level: 5. Accountability Agreements with Health Service Providers (HSPs) updated to support tracking of each HSPs contribution to the overall regional objectives / goals 6. Care coordination role implemented through collaboration with all palliative care HSPs across the continuum of care 7. Outreach processes established across all palliative care HSPs across the continuum of care to identify individuals with advanced chronic disease and connect them with an extended inter-professional team 23

24 Integration of New Community Based HPC Nurse Practitioners into their Regional HPC Programs Program Description / Goal Contribute to the best quality of life and death for palliative clients and their families and to reduce avoidable ED visits and hospitalizations The program involves 24/7 coverage for palliative clients Role of Nurse Practitioner Support Most Responsible Physician (MRP) to ensure continuity of care for individuals with complex palliative needs across all care settings Provide consultation and mentorship Establish strong partnerships and create care connections with primary care, specialized palliative care, acute care and community care Target Population Clients with complex palliative needs or high risk characteristics (shared care clients receiving direct care from NP) Clients with stable palliative needs (coordinated care clients where NP provides clinical expertise) 24

25 Palliative NPs (continued) LHINs collectively support launching the new community-based palliative care programs / networks All LHINs have outlined plans that: Enhance team-based care through integrating new NP positions into existing care teams Enhance care coordination across all care settings and levels of care (primary, secondary, tertiary) Compliment existing services to increase community service capacity to support individuals in their homes Increase capacity 24/7 access to care support through integrating with existing team-based coverage Create NP/MD/FHT collaborative partnerships LHINs are leading the development of performance metrics for measuring impact of the community-based palliative care NP program. 25

26 LHINs support Ministry to Develop an Integrated DATA Strategy to Measure Progress Relative to Key Targets LHIN leadership for performance measurement would be optimized to strengthen alignment across multiple initiatives currently examining palliative indicators 26

27 Big Dot Aim Indicator This aim is defined as a 10% reduction in the total number of hospital days attributed to palliative care, and is based on the following methodology: Averaged 3 years of acute in-patient days (total days) to determine 10% reduction in Total Days Baseline = Average Total Days over last 3 years ( ) Total Days = Total ACUTE Days and Total ALC Days Rate of growth accounted for based on 2011/2012 rate of change at 3.7% Patients identified as palliative using ICD-10CA code Z51^^ Using discharge disposition of death was not considered as it does not distinguish patients hospitalized for palliative care 27

28 Supportive Measures for Big Dot Aim Supportive measures have been identified to reflect the need to increase supported end of life care and ensure quality of care and patient experience: # of patients discharged home with support # of patients discharged home without support # of ALC days (subset of total days including total LOS) # Average total LOS # of patients died in hospital 28

29 South West LHIN Hospice Palliative Care Services In the South West, 360 people (17%) died at home in Q4 2010/11. Almost 2 years later, Q3 2012/13, 470 people (22.3%) died at home. The provincial comparator is 21.4% in Q4 2010/11 and 24.8% in Q3 2012/ % of palliative patients in the South West LHIN experienced multiple acute care admissions in the last 3 months of life (2011/12) (Data Source(s): Discharge Abstract Database (DAD), Continuing Care Reporting System (CCRS), National Ambulatory Care Reporting System (NACRS), National Rehabilitation System (NRS), Ontario Mental Health Reporting System (OMHRS), CIHI, extracted from Health Data Server, MOHLTC, May Registered Persons Database (RPDB), Claims History Database (CHDB), MOHLTC, extracted May Home Care Database (HCD), OACCAC, extracted from Health Data Server, MOHLTC, May Health Based Allocation Model (HBAM) 2011/12 CCAC services cost, MOHLTC, May 2013 Amongst palliative care hospital encounters in Q1 2013, 20% of days in hospital were ALC (DATA Source: Hospital Discharges Main Table, Ontario Ministry of Health and Long Term Care, Intellihealth Ontario, Data Extracted November 28, 2013) 29

30 Ministry / LHIN Development of Residential Hospice (RH) Policy Framework (RH) Policy Framework to establish a more strategic and consistent approach to RHs LHINs see RHs as important for system transformation in terms of providing a more cost effective and more appropriate care setting than hospital-based palliative care. By developing a more robust RH presence in targeted communities, LHINs expect to significantly reduce hospital expenditures and achieve net system savings. By updating RH policy to align with LHIN integration strategies as well as the ministry s fiscal plan, LHIN and stakeholder expectations can be more strategically managed while improving access and equity for more Ontarians. 30

31 Coalition Implementing Complementary Actions Advancing the Priorities within the Declaration QHPCCO (Coalition) Actions from the Declaration include: Supporting early identification of care needs through expanding provincial representation to include chronic disease associations Strengthening caregiver supports through: Identifying best and leading workplace policies / practices across Ontario that support employees to take compassionate leave Centrally coordinating common information guides and develop a common toolkit for caregivers Promote the adoption of evidence based best practices and build readiness to implement cross-sector accountability Working with partners to explore options and seek opportunities for increasing general public s understanding and awareness 31

32 Ministry / LHIN Commitment to Collaborative Leadership Structure *In order to ensure accountability, the collaborative leadership would establish an annual public report on the implementation, progress, impact and performance results against action commitments. 32

33 South West LHIN Integrated Health Service Plan (IHSP) IHSP Strategic Direction #2 emphasizing HPC QI work Improve Coordination and Transitions of Care for Those Most Dependent on Health Services Objectives: 1. Continually respond to the needs of the evolving population of people with the greatest unmet health care needs utilizing a significant proportion of the health care resources 2. Create a collaborative person-centered response to better support the growing population of people living with chronic conditions and those at risk 3. Enable people to manage their health

34 South West LHIN Goals To understand the service delivery model we are trying to create; To create a Network structure that has the accountability, authority and mandate to achieve the goals outlined in the Declaration of Partnership; and To align the Network lead position and other required resources to support achievement of goals

35 Next Steps: Regional Hospice Palliative Care Program Vision 24/7 care settings Long Term Care Homes Hospitals - Complex Continuing Care Residential Hospices Hospitals - Acute Care (including host hospital for RCP) Patients Home* (CCAC & CSPA etc.) Ambulatory care/day Programs and Community Support Services Hospice Palliative Care Program Visiting Physician Program Expert HPC Nurses & Nurse Practitioners Expert Multidisciplinary Professionals Palliative Pain and Symptom Management Consultation and Education Programs cross sector education and consultation to formal care providers Volunteer Hospice Programs Community Hospices Outpatient Clinics Etc. Cross sector *- Patient s home refers to any location where patient is residing (outside of settings included here). This may be a Community Living residence, Group home etc. ** - Outpatients refers to ambulatory & transportable patients & families 35

36 South West LHIN Hospice Palliative Care Program Regional Consultation for complex palliative issues Research and evaluation Drive clinical practice standards Multi-Community Consultation and support to Primary Care Available 24/7 Mobile Support primary care team as key service provider Education to drive best practice Primary Care Daily, hands on 24/7 primary care for palliative patients in their home Intensive Care Coordination Patient and Family Teams Comprised of: Tertiary Care Palliative Program LHSC, Parkwood NP Team Paediatric Palliative Consultation Program Palliative NPs Palliative Specialty Physicians Residential Hospice Palliative Pain and Symptom Management Consultation Program Primary Care Care Coordinators Community Care Service Providers CAPCE Trained Hospice Volunteers Community Hospitals Clergy 36

37 South West LHIN Quality Improvement Enabling Framework (QIEF) Performance based incentives Recognition (Quality Awards) Celebrating Leading Leadership Governance Strategic priorities Priority setting Partnering Defining Accountability Health Policy Relentlessly Telling the Story Communicating People/Stakeholders Motivating Engaging ehealth Standardization of EMR/ EPR Enabling measurement through Business intelligence/decision support Person Centered Right Action and Right Intervention Enhancing Health Information Systems Building System Capacity Applying evidence decision making Knowledge and Translation Education & Training Change Management Best Practices in non- Clinical and clinical Care Performance measurement Research Quality Framework References 2011: Capital District Health Authority, Alberta Health Services, National Health System, Ontario Council on Community Health Accreditation and Niagara Health System, IHI, Baldridge Performance Excellence Program

38 South West LHIN QIEF & Alignment to Declaration of Partnership (2011) Celebrate success and QI achievements Leading Accountability to integrate delivery as part of a virtual team Comprehensive integrated HPC program that includes interagency accountability Accountability agreement to ensure collaboration Build primary care physicians into the community based team community outreach Partner with existing provincial palliative care initiatives in LTC Identify and engage people who are marginalized who would benefit from care Include client and family in care conferences Motivating Engaging Leverage technology solutions as enablers for integration and coordination Leverage technology to improve access (e.g.) ONT, e-shift) Person Centered Right Action and Right Intervention Enhancing Health Information Systems Building System Capacity Applying evidence decision making Strengthen and leverage access to palliative care expertise at all levels Establish mentoring / coaching program in each interprofessional team Standardized delivery across all care settings Align with CHPCA standards (screening tools, practice guides, best practice tools) Benchmarks for access

39 Improving the Experience for Individuals receiving Hospice Palliative Care Turning experiences in action! The Experience Based Design approach is different from many other improvement or change initiatives in that it encourages you to work closely with both patients, carers and staff in developing a better experience for all. Involving patients, carers and staff as partners in design in solutions for the Hospice Palliative Care service can lead great improvements and healthcare journey / experiences for all. Engagement/Partners-in-Care-Resourcepage/NHS-EBD-Guide pdf 39

40 Opportunities (EBD): Experience Based Design Approach

41 Opportunities (E-Health): Clinical Connect a secure web portal, or Viewer, that makes it possible for health care professionals to see a patient s medical information from separate information systems. 41

42 Opportunities (E-Health): E-Shift is an innovative program launched in 2010 where (PSWs) receive specialized training and technology tools to provide clients bed-side, in the home care end-of-life stage care. 42

43 Opportunities (E-Health): HealthChat.ca new online tool enables multiple users to create a profile (or space) where information can be shared and used to communicate or chat. 43

44 Structure HPC Lead ToR & work plan with each collaborative South West LHIN Hospice Palliative Care Leadership Committee Oversight Committee Responsible for: System Design Capacity Planning Learning and Development Performance Measures/Monitoring Clinical Standardization Clinical Coordination / Common Clinical Processes Oxford Hospice Palliative Care Collaborative Elgin Hospice Palliative Care Collaborative Huron Perth Hospice Palliative Care Collaborative Middlesex London Hospice Palliative Care Collaborative Grey Bruce Hospice Palliative Care Collaborative Care Collaborative: Local palliative care representatives including Executive Sponsor(s)/ members that are key local decision-makers Activities: Local service planning for palliative care within each community; identify local system capacity needs/gaps; local CQI; oversight of local capacity building activities, etc.

45 Questions?