Documented assessment of palliative care needs among patients identified to benefit from palliative care (long-term care sector)

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Documented assessment of palliative care needs among patients identified to benefit from palliative care (long-term care sector)

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Most patients in our health care system should be receiving a palliative care approach much earlier than they often do. Ultimately, receiving timely palliative care provides benefits for patients, caregivers and the health system, often supporting patients to die in their preferred place of death with the supports they need. Health care providers in all sectors have a role to play in identifying patients who could benefit from a palliative care approach.

Click here for a visual guide outlining how to measure this indicator.

Tips

You can select one or more of the change ideas or tools below and use this PDSA worksheet to help test your change ideas. You can learn to select the most appropriate process indicators by reading this Measurement Guide.
To prioritize a change idea to include in your QIP, consider choosing one that addresses a known gap within your care team (i.e., ensuring care teams have confidence to have difficult conversations); standardizes or enhances an existing process (i.e., choosing an early identification tool and developing a process to identify); and/or provides an opportunity to build greater patient and caregiver engagement (i.e., create a palliative care plan to support patients and caregivers).
Email palliative@hqontario.ca to join the mailing list for monthly webinars and other supports.

Key resources

Change Ideas

Select and use tools that support early identification

Review the Tools to support Earlier Identification for Palliative Care toolkit, then:
o Engage staff in choosing and testing the tool to ensure uptake
o Embed the chosen tools into your electronic medical record system
o Use flags in EMR when changes in medical or functional status occurs to prompt clinicians to screen or re-screen for palliative care needs

Ensure patients identified early have a holistic assessment completed

Educate interprofessional staff on the Domains of Issues Associated with Illness and Bereavement
Domains of Issues Associated with Illness and Bereavement
Map out current assessment process to assist in determining gaps
Process Mapping Instructions and Worksheet by Health Quality Ontario
Develop a future state process to leverage interprofessional team members’ expertise to complete the holistic assessment and plan ongoing care

Support health care providers in communicating with patients and their families about palliative care

Provide education and skills training to staff on communication and having difficult conversations
Hospice Palliative Care Ontario’s Implementation Resources
Provide guides or prompts for clinicians to help them in having difficult conversations
Person-Centred Decision Making (PCDM): Advance Care Planning, Goals of Care Discussion and Health Care Consent Tool Kit by Speak Up Ontario
Review information guides, pamphlets and brochures with care team members to ensure they feel confident discussing content with patients and families
Create a care plan in a format that can be shared with patients
Coordinated Care Plan user guide and template by Health Quality Ontario

Foster collaboration and communication internally and across care settings

Explore opportunities for digital tools and technology for palliative care planning and referrals
Enhancing Long-Term Care Through Electronic Clinical Support Tools
Explore virtual platforms for connecting with specialists or with patients, especially in remote areas
The Ontario Telemedicine Network’s eConsult, eVisits, and Virtual Palliative Care programs
Reach out to your Regional Palliative Care Network to get information on supports and partners in your area
Contact info@ontariopalliativecarenetwork.ca to get more information
Share resources (staff, technology, or training opportunities) amongst partners in your region (i.e., sharing and co-funding an NP amongst partners within a region, holding regional educational events)
Ensure personal support workers have a way to alert registered staff or document when they notice a change in resident status, especially for those patients who have already been identified with palliative care needs.

Ensure providers have the skills and confidence to provide palliative care

Provide education and training to staff in required palliative care competencies
View courses provided by Pallium Canada and leverage resources from Hospice Palliative Care Ontario and the Ontario Palliative Care Network
Develop a process to determine if staff skill and confidence is improving, incorporating audit and feedback
How to Conduct an Audit for Your Training Programs by HR Daily Advisor

tags:

Palliative Care