PREAMBLE On January 20 th the Clinical Council of the Hospice Palliative Care Provincial Steering Committee presented and articulated the Essential Minimum Clinical Standards for Hospice Palliative Care in Ontario (see attached). The are: a suite of 12 interconnected clinical standards. based on documents that represent broad stakeholder engagement as well as consensus and recommendations from experts in palliative care. built on best and most current evidence in palliative care the critical actions and next steps articulated in the PCS will build upon the important work already happening throughout the province. The PCS are considered a starting point for standardization of clinical direction in the province, while enabling regional customization and contextualization. They detail interconnected priority areas that need to be addressed in order to improve palliative care in Ontario. The Clinical Council is an inter-professional council comprised of 11 Palliative Care clinicians with diverse and relevant palliative care skills sets who applied for Clinical Council positions which were selected by the Hospice Palliative Care Provincial Steering Committee. The Clinical Council was tasked with creating clinical standards related to palliative care in Ontario and did so using an evidence based approach to articulate the most important areas requiring minimum clinical standards. This process began by developing a consensus driven Clinical Change Strategy outlining an approach and highlighting key directional documents that were used as evidence to determine the most important clinical areas. Each directional document represents consensus recommendations from experts in palliative care and collation of evidence, and best practice. The process of developing the built upon the best and most current evidence in palliative care. Similarly, the PCS document outlines critical actions and next steps that will build upon many components of excellent work that already exists within the province. The attached document contains the 12 PCS outlining the critical actions, next steps and directional document for each standard. The attachment also contains graphics that outline the interdependencies of the PCS and maps the PCS to the hospice palliative care model outlined in the Declaration of Partnership. At this time the Hospice Palliative Care Provincial Steering Committee is circulating the Provincial Clinical Standards to our partners with the intent of: 1. Seeking input from our partners, specifically with respect to overall direction of the PCS. 2. Fostering discussion. The PCS documents can now be used as regional and organizational tools to assess readiness to move forward with implementing pan-ontario palliative care standards. Please share this document with your palliative care providers, and other relevant stakeholders. Feedback related to the PCS can be forwarded to Deanna Bryant, Project Lead, at Deanna.Bryant@cancercare.on.ca or 416-971-9800 ext 3761 1
Title: Essential Minimum Clinical Standards for Hospice Palliative Care in Ontario Phase One PCS 1: A Regional Hospice Palliative Care Program (Regional Program) and structure is operational at each LHIN with clear, transparent accountabilities to the LHIN that outlines health service provider (HSP) responsibilities to stakeholders and consumers. The Regional Program will have standardized clinical deliverables as outlined by the Ministry of Health and Long- Term Care (MOHLTC) and the Ontario Palliative Care Network (OPCN). Patient reported outcomes and quality indicators will drive system change. A transparent and inclusive process has been or will be used to create a Regional Program whose structure meets regional stakeholder and consumer needs as well as system requirements and includes a Regional Program Director and unified Regional Clinical Leadership Each LHIN develops accountability or terms of reference (TOR) agreements with their Regional Program Regional Program Directors have a shared accountability agreement with Regional Programs Regional Program Clinical Leads have standardized role descriptions and accountability agreements with both their Regional Program and LHIN and with the OPCN Clinical Council Regional Program and Directors/Clinical Leads develop shared accountability agreements with stakeholders and consumers/community to: o Customize & contextualize PCSs o Benchmark the PCS Regional Program Director roles are created and positions filled OPCN Clinical Council - develops/creates the unified Clinical Leadership role(s) Regional Program Clinical Leads are identified Regional Programs create and enact a regional work plan Regional Programs create a process to establish partnerships with patient and family advisors To achieve true patient centered care (as per the Declaration deliverables) one agreed upon and collaborative process of palliative care delivery needs to exist at each LHIN Recommendation 6 Residential Hospices Working Group (RHWG) Declaration of Partnership (Declaration) (p.33) 2012 LHIN Implementation Plan OHTAC Recommendation 2
PCS 2: A Regional Public Health Strategy exists as a standard element of each Regional Program, which includes detailed work plans outlining responsibilities at the provincial, regional and local levels. PCS 3: a. All health service providers receive essential Hospice Palliative Care (HPC) training to maintain and deliver minimum standards of HPC o Track and measure clinical performance based on standardized system performance indicators OPCN Clinical Council - collaboration and partnership with Public Health Ontario to establish provincial palliative care public health standards Regional Program partnerships with regional and municipal Public Health Departments are established Work plans to include the development of a Regional Public Health Strategy Public education is a standard component of Regional Program work plans MOHLTC & Ministry of Training, Colleges and Universities (MTCU) and Regulated Health Professional Colleges establish a method to collaborate that connects curriculum with practice to meet minimum standards of HPC Regional Programs - unified Regional Education Collaboratives are OPCN Clinical Council - development and dissemination of best practice palliative care public health guidelines Regional Programs, Directors and Clinical Leads together with public health expertise and members of the community, determine their roles, develop work plans and initiatives that meet provincial standards OPCN/Regional Programs-create alignment, and re-orientation of existing MOHLTC Palliative Care Initiative 3 Supporting and Maintaining Hospice Volunteer Visiting Programs to support a Regional Public Health Strategy Regional Programs to establish an accountability framework for healthcare organizations and standardized approach to staff and clinician development Existing regional palliative care educational resources (MOHLTC Palliative Care Initiatives # 1,2, and 4) be collaboratively re-aligned as A sustainable system requires the community as full partners; aging, loss and bereavement are everyone s responsibility, not just health care providers. Ontario Health Technology Advisory Committee (OHTAC) Recommendation 4 RHWG Patients across the province will receive care from health service providers who have all received the same essential level of hospice palliative care training, which ensures quality care is provided. 3
established to coordinate regional educational needs and resources Pallium LEAP courses are coordinated centrally in each region as a deliverable of the Education Collaborative base for a unified Regional Education Collaborative and resultant work plans MOHLTC Palliative Pain and Symptom Management Consultants role (MOHLTC Palliative Care Initiative 4) be realigned to include LEAP Coaches for each Regional Program Regional Programs asset map existing resources and create region wide mechanisms towards standards, shared deliverables and shared resources OHTAC Recommendation 4 RHWG b. ALL specialized HPC team providers achieve and maintain specialty level training in hospice palliative care and maintain clinical practice standards All relevant Ontario accrediting Colleges (i.e. OCFP, College of Nurses, RCPSO, etc.) collaborate to articulate, establish and deliver professional development standards for minimum and specialized HPC standards Regional accountability for ensuring professional development of existing HPC teams & minimum practice standards OMA OHTAC c. A Health Human Resource (HHR) strategy for hospice palliative care specialized clinicians is developed and implemented for the province; this includes physicians, nurses, nurse practitioners and other allied health professionals. Develop minimum standards of sustainability for specialized HPC clinician s (see PCS 11) Regional programs articulate their future steady state HHR goals based on existing best practice models Province/MCTU/MOHLTC/OPCN increase specialty level physician training positions (fellowship training) by an agreed upon number and yearly increments OMA CSPCP Human resource assessment 4
PCS 4: Physician remuneration for palliative care is standardized and includes: a. A new province wide, regionally affiliated AFP for focused palliative care practice b. Family physician billing and fee codes unique to primary care support primary care engagement in the provision of palliative care (e.g. G512) c. Fair, equitable and unique billing/fee codes for all physicians to support both palliative care related interventions (e.g. ACP and goals of care discussions) as well as integrated models of partnership and collaboration d. Equitable funding for palliative care groups providing hospital on call coverage e. Equitable funding for groups providing community on call services in primary level or consultation/shared care models f. Providers participating in a Patient Enrollment Model (PEM) will provide direct palliative care to their patients g. Primary care providers are able to prescribe EOL medications OPCN Clinical Council to establish and oversee provincial physician remuneration standards which in Phase One include: a. The existing GP focused AFP in Palliative Care is eliminated and replaced or provincially revised and standardized b. The existing Hospital On-Call (HOC) funding structure is revised to include acute care palliative care consult teams on call, or a new hospital/regional on call is developed c. The proposed Community Palliative On-Call (CPOC) funding to be aligned with new provincial palliative care standards d. Accountability agreements and recognition awards developed to support FHTs, FHOs and FHGs to deliver direct palliative care e. The Palliative Care Facilitated Access (PCFA) medication coverage program is re-vamped to be: Fully accessible to primary care providers for regionally rostered palliative care patients Less restrictive Open to ongoing adjustments to match standard of care medications to prescribing practice With the aim of formally collaborating to develop a unified and sustainable regional physician strategy, Regional Programs engage all stakeholders with palliative care HHR assets or deliverables to compile an asset map of existing resources to build unified work plans i.e. Regional Physician Strategy? The Regional Physician Strategy includes primary care leadership Funding models support policy directions that encourage primary care to be involved in providing palliative care to their patients across setting of care and in collaboration with a specialized hospice palliative care team when needed OMA Recommendation 3 RHWG McMaster health forum 5
PCS 5: Utilization of a province wide HPC EMR connectivity platform with the ability for patient navigation and cross sector health service provider access in real time PCS 6: Values and goals-based conversations inform advance care planning (ACP) processes and decision-making around consent for standard end-of-life treatment plans and address common end-of-life decisions (i.e. beyond code status, e.g. POST). Previous discussions and decisions are accessible to patients, substitute decision makers and clinicians 24/7. Provincial level investment in vendor with the ability to connect existing databases and develop a P palliative care EMR platform Regional development of collaborative partnerships with existing stakeholders and EMRs to begin to develop a registry (see PCS 7) Work plans to include implementation of standardized system performance indicators and data collection OPCN Clinical Council establishes provincial standards for both an ACP Conversation template & a Serious Illness Treatment Plan Regional Programs oversee the development and implementation of ACP and Serious Illness Treatment Plan strategies as core elements of Regional Work Plans ACP Conversations are a clinical imperative for all registry patients Serious Illness Treatment Plans are a clinical imperative at the time of admission to any facility and are routinely revisited throughout stay Provincial HPC EMR customized and partnered as part of the work plan of each Regional Program Healthlink connections with each Regional Program Data collection and management centralized and overseen by each Regional Program Registry development part of the work plan of the Regional Program - fostering both organizational use and alignment towards a Region wide registry Resources of Regional Program assist with organizational registry development OPCN Clinical Council to strike short term and time limited expert panels with the aim of recommending tools and processes aligned with the provincial Health Care Consent Act and the National ACP Framework The MOHLTC Palliative care consultants role (PC Initiative 4) be re-aligned to include ACP and Care Plan Coaches for each Regional Program A unified, real time EMR is essential to follow a patient across care settings to allow for the provision of safe care Recommendations 2 & 7 RHWG GSF HPC Steering Committee Data and Performance Working Groups recommended indicators Provincial standards will help patients to begin the process of planning for the future and will facilitate decisionmaking when considering consent for proposed treatment plans OMA OHTAC Recommendation 7 RHWG 6
PCS 7: The Gold Standards Framework (GSF) approach of identify, assess and plan/manage and the Palliative Approach to Care are operationalized by utilizing Regional palliative care patient registries and ongoing components of regional work plans Regional Programs and LHINs to adopt and adapt the GSF to utilize regionally Registry development intra and inter-agency and cross sectorially The MOHLTC Palliative care Consultants role (PC Initiative funding number 4) be re-aligned to include GSF Coaches for each Regional Program Resources of Regional Program assist with organizational registry development which includes the care team level Registry development is part of the work plan of the Regional Program - fostering both organizational use and alignment towards a Region wide registry that meets patient and community needs Pilot project involving engaged LHINs to proceed Regional application of the provincial strategy as part of Regional Program work plan Early identification, evidence based assessment and management across a patients journey is the international person centred, sustainable and cost effective best practice OHTAC Recommendation 1 RHWG McMaster health forum PCS 8: A provincial pediatric palliative care strategy with tertiary care and community standards OPCN Clinical Council adopts and endorses existing Pediatric Provincial Standards Implementation of Inter-Regional Nurse Practitioner Mentor model Children and their families need access to palliative care too. The provincial strategy will provide increased equity and access to palliative care for pediatric patients and their families in their own local community as well. Declaration Recommendation 1 RHWG CHPCA POGO 7
PCS 9: An Aboriginal Palliative care strategy for PC community development The Kelley Community Capacity Development model for PC is adopted by each Regional Program Each Regional Program in partnership with First Nations, Inuit and Metis oversees the implementation of their Aboriginal Palliative care strategy First Nations, Inuit, and Metis need equitable access to culturally safe palliative care services in the setting of choice. PCS 10: The Palliative Approach to care is a standard component of each primary care practice as well as primary level providers practice Regional Programs are tasked with realigning, reorienting and consolidating resources to enable development of the Palliative Approach to care as a regional standard and deliverable Regional Programs will foster and enable consultative and shared care models. Substitution models of care should be a limited resource, based on case complexity and only exist as a result of an agreed upon process that is contingent on a regional work plan Regional Programs develop formal linkages between specialized HPC teams and primary care as a standard component Regional Programs to establish 24/7 access of specialized HPC teams to primary care Realignment of existing funding for Palliative Care Consultants (MOHLTC Initiative #4) to Regional Program to support registry developments and navigation Realignment of the MOHLTC Palliative Care Nurse Practitioner program to Regional Program to support 24/7 both primary care and specialized HPC teams in support of patients on regional registries Registry development in practices and across regions OHTAC Recommendation 2 RHWG Recommendation 3 RHWG Kelley report To meet the societal palliative care needs of an aging population, basic or primary level palliative care needs must be addressed by clinicians other than palliative care specialists. Ideally primary care teams will provide most of this care but we also need oncology, cardiology, nephrology, etc teams to be providing some of the basic palliative care as well Recommendation 3 RHWG OHTAC 2012 LHIN Implementation Plan 8
PCS 11: Specialized HPC teams follow patients within and across care settings from first identification to bereavement and are adequately developed and resourced across each LHIN to support patients and primary providers Regional Programs realign resources from organizations that currently or should provide HPC across sectors to create comprehensive specialized HPC teams with shared accountability. This includes willingness to realign current resources including home and community care. Regional Programs to outline a process for HPC teams to be a shared deliverable for the region. Cocreated and collaborative accountabilities are shared among LHIN leadership, Regional Program, hospitals, CCAC OPCN Clinical Council - articulates guidelines for a standard of: a. All specialized HPC teams as teaching teams b. Capacity building c. Mentorship d. Team deliverables e. Team meetings for registered patient care planning f. Bereavement care g. Care for the caregiver OPCN will identify and address existing legislative and policy barriers that inhibit the implementation of cross sector specialized HPC teams Regional programs create planning groups with relevant stakeholders Mechanisms created at the regional level to involve primary care leaders in collaborative planning Patients, families and primary level providers have told us they want equitable access to specialized palliative care when needed and evidence tells us HPC teams are best practice. Recommendation 3 RHWG OHTAC 9
PCS 12: A standardized population based approach and comprehensive plan for regionally appropriate settings of care will be utilized. This includes appropriate resources for home deaths and resources for an appropriate mix of residential hospice and tertiary palliative care beds. Home care resources and funding are organized to follow the patient across settings of care. OPCN Clinical Council: o Define and articulate provincial standard for bed types including palliative care units (PCUs) other acute care and chronic care/ltc beds and residential hospices Provincial Standards are established for funding and staffing of acute PCUs and residential hospices Palliative Care related Quality Based Procedures (QBPs) are developed that include interprofessional teams for all diseases (including heart, lung, renal and neurological), applicable across the illness trajectory and not just at the end of life. Regional Programs leverage patient centered Community Hubs that inform, educate and support informal caregivers and create clinical communities of practice for health service providers Regional programs support realignment of home and community care resources and funding for patients receiving palliative care Development of funding models to Provincial - performance indicators for PCUs are fine tuned to better represent both the patient populations on these units and the role of the PCU Provincial - residential hospices are 80% funded Regional - gaps in existing acute PCUs and residential hospices that prevent meeting provincial standards are addressed as part of regional program work plans Develop a policy that will ensure the implementation of the Expected Death in the Home (EDITH) protocol across Ontario. This will facilitate death with dignity and prevent the performance of CPR on persons receiving palliative care who are expected to die. A sustainable system requires the right mix of resources across care settings to meet patient needs Recommendations 1, 3, 5 RHWG 10
follow the patient to provide equal access to service whether at home or in an institution. (eg in addition to home care; access to medications, transport services for tests/investigations) Define parameters of home care services based on clinical pathways that incorporate clinical, functional and psychosocial needs of the patient and caregiver. Directional Documents 2012 LHIN Implementation Plan Letter from Hospice Palliative Care Provincial Steering Committee Co-Chairs Advancing High Quality, High Value Palliative Care in Ontario: A Declaration of Partnership and Commitment to Action 2011 (The Declaration) Canadian Society of Palliative Care Physicians Human Resource Assessment Gold Standards Framework (GSF) Hospice Palliative Care Steering Committee s Data and Performance Working Group Recommendations Community Capacity Development in Palliative Care: An Illustrative Case. Study in Rural Northwestern Ontario McMaster Health Forum Citizen Brief: Improving Access to Palliative Care in Ontario McMaster Health Forum Panel Summary: Improving Access to Palliative Care in Ontario Ministry of Health and Long-Term Care Palliative Care Initiative Ontario Health Technology Advisory Committee (OHTAC Recommendations) Ontario Medical Association End of Life Care Strategy Report of the Paediatric Palliative Care Work Group October 2011 Residential Hospices Working Group Report (RHWG) 11
Essential Minimal Clinical Standards for Hospice Palliative Care in Ontario System & accountability The public Clinicians Tools to improve direct care PCS 1. REGIONAL PROGRAMS PCS 2. PUBLIC HEALTH STRATEGY PCS 3. PROFESSIONAL DEVELOPMENT & EDUCATION PCS 4. PHYSICIAN WORKFORCE PCS 5. E-HEALTH & TECHNOLOGY PCS 6. ADVANCE CARE PLANNING & END-OF-LIFE TREATMENT PLANS PCS 7. GOLD STANDARDS FRAMEWORK - REGISTRIES Direct care (Teams & settings) PCS 8. PAEDIATRIC CARE PCS 9. ABORIGINAL CARE PCS 10. CAPACITY BUILDING: PRIMARY LEVEL PCS 11. HPC CONSULTANT TEAMS PCS 12. RESIDENTIAL HOSPICES & PALL CARE UNITS 12
Inter-Relationships and Dependencies among the 12 PCS 10 8 # this PCS IS NEEDED BY # this PCS WOULD SUPPORT # this PCS COULD USE THE SUPPORT # this PCS NEEDS 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 Each PCS relates in some way to each of the other 11 PCSs - this is a visual representation of these relationships The vertical axis represents the number of other PCSs and the shading represents one of four relationships For each PCS, the darker the shade the more so this PCS is needed by other PCSs For each PCS the lighter the shade the more so this PCS needs other PCSs 13
PCS Mapped to the HPC Model from the Declaration of Partnership 14