4 Registration on Program Patients can be “registered” on the Palliative Care Program if they meet program criteria:Prognosis of less than 6 monthsNo longer receiving aggressive treatment which requires on-going monitoring for and treatment of serious complicationsHave chosen a comfort-focused approach including a decision to decline attempted resuscitation
5 Registration on Program Once registered with the program, patients are eligible for:Case management through Palliative Care CoordinatorAccess to Community Palliative Care Nursing 24/7Palliative Care Nurses have access to Palliative Care PhysicianAdmission to Palliative Care Units (PCU) and Hospice – if bed availableEnrollment on Provincial Palliative Care Drug Access Program
6 When to Register a Patient on Palliative Care Program Patients are considering going home from acute careNeed to plan for services to be in placePatients being transferred to Long Term Care Setting
7 How to Register a Patient on PC Program Complete the “Application for Registration” form2 page form“completed” forms can be processed more quicklyCompleted forms are reviewed by PC coordinatorAccepts on to ProgramRejects application – all reviewed by Manager, Program Director or Medical Director
8 Acute Palliative Care Units (PCU) Admission to PCU for symptom issuesPhysical symptomsPsycho-social distressCaregiver distressAdmissions managed centrally by PC program staffBed management guidelines
9 Acute Palliative Care Units St. Boniface Hospital15 bed unitAccess to tertiary care servicesRiverview Health Centre30 bed unit (2 beds currently closed)Long term care facility
10 Acute Palliative Care Units Once symptoms are controlled, actively discharge to appropriate siteApproximately 75% of patients die on PC unitApproximately 20% of patients are discharged home from Palliative Care UnitsLack of care options if home not possiblePCHChronic CareHospice
11 Hospice settings in WRHA Grace Hospice12 beds in stand alone facility near Grace hospitalRN staffing 24/7Limitations in care that can be provided
12 Hospice settings in WRHA Jocelyn House4 beds in split-level home in St. VitalRN staffing 4 hours a day – 5 days a weekHCA provide care 24/7
13 Hospice Hospice is appropriate when: Symptoms well controlled Care needs are not complexPrognosis of 1 – 3 monthsPatients cannot or do not wish to be cared for in the community
14 Care at HomeMajority of patients on Palliative Care program are in the communityPalliative patients in community have same service limitations as all Home Care clientsHCA and PSW services provided by Home Care ProgramFamilies/caregivers must be very involved in providing care
15 Community Teams:Community NursesCNSMDCoordinatorPsychosocial
16 Inter-professional Community Model Implementing EMRWill allow all members of Palliative Care team in community to chart on one charting systemWill improve information sharing and communication between primary care providers (using EMR) and palliative care providers
18 Consultative Services Available to anyone with a life limiting illness in any care setting for symptom management, psycho-social support or assistance with discharge planningConsultation services are provided by inter-professional team members including:Palliative Care PhysicianPalliative Care Clinical Nurse SpecialistPsycho-social Support Specialist
19 When should Palliative Care be consulted? Assistance with symptom issuesManaging Physical symptomsMD to MD consults for advice 24/7Psycho-socialAssistance with care planningWhat might care team expect as patient nears end of life?Will oral route be available?Could symptoms escalate?
20 When should Palliative Care be consulted? Goals of care are not clearDiscrepancy between patient, family and/or members of care team with plan of careDischarge to community or LTC is anticipatedDoes patient need to be or are they currently “registered” on Palliative Care program?Would it be appropriate for Palliative Care nurse to see the patient in the community?
21 What information is needed on consult? Main reason for consultWhat is the main symptom issue?Urgency of consultIs the physician aware of the consult?
22 How to contact Palliative Care Program One number to call if you have questions or need a consultation during business hours:Do not page Palliative Care team members directly or leave messages regarding consults on their office phones.
23 How to contact Palliative Care Program Physician to physician consultation available 24 hours a day – 7 days a week:204 –
24 Community Palliative Nursing Consult ServiceCommunity Palliative NursingCase CoordinatorAdmission EligibilityMedication Coveragecomfort-focusedprognosis “6 mo. or less”some treatment limitations (DNAR, no TPN, no chemoTx with high adverse effectsaggressive, often toxic treatment focused on cure or life-prolonging disease modificationDiagnosis ofLife-LimitingIllnessTransitioningto PalliativePalliative
25 Increase capacity through education, advocacy, FormalProgramPalliative Care as aphilosophy of careResourcesIncrease capacity through education, advocacy,partnerships