Palliative care in Windsor and Essex County is provided by
numerous professionals and organizations including Hospice of Windsor and Essex
County, primary care and palliative care physicians, LHIN Home and Community
Care and service provider agencies, Windsor Regional Cancer Program, Windsor
Regional Hospital, and other local hospitals.
Services were not always aligning between these
organizations and there was often duplication in services and gaps in others.
Hospice of Windsor and Essex County, Windsor Regional
Hospital, and LHIN Home and Community Care participated in the
to improve patients’ transition from hospital to home and ensure
appropriate referrals to palliative care community services.
Our aim statement was as follows:
- 80% of clients discharged from the inpatient
oncology unit at Windsor Regional Hospital with a Palliative Performance Score
(PPS) at or below 60% will be referred to the appropriate community service by
October 31, 2018.
We partnered with the inpatient oncology unit team to ensure
the project was manageable and to measure our success before spreading the
Cross organizational partnership:
Our team started by completing a fish bone diagram to
determine the root cause of why palliative care services were not aligning well
between organizations. We found that most referrals were coming from family
physicians and the LHIN nurse practitioners, and few from other sources such as
Partnering with organizations
was an important place to start. Our hospital partners committed to learning
about the services provided by the hospice and the LHIN. The hospice and the
LHIN also took time to understand why referrals weren’t occurring in a timely
We also completed a stakeholder analysis to determine who
needed to be involved, who would be affected by the change, or could affect
change, and at what point in the process to best execute a training and
By engaging our stakeholders, we were able to learn what the
barriers were for each organization and address their needs along the way to
maximize buy-in. We received important feedback that shaped the approach to our
Our core team included three members from three
organizations: The Hospice of Windsor and Essex County, Windsor Regional Hospital,
and Erie St Clair LHIN Home and Community Care. The lead for this project was
Janet Elder, a palliative liaison coordinator, which was an existing position
to liaise between the hospital, the LHIN, and the hospice.
In the hospital, we worked with the palliative care liaison
nurse. Her role was limited to working within the hospital but expanded through
the IDEAS program to work effectively with external organizations.
Change idea: Improving the referral process
Through consultation with our hospital stakeholders, we
discovered that the current referral form was in fact a barrier to referring
clients to palliative care services. There was a disclaimer on the referral
form that stated, “I understand that I will continue to be involved in the
ongoing care of this patient,” which was not relevant for hospital physicians.
Another barrier was that the hospital team had no mechanism to refer clients to
other services such as social workers or volunteer services since these
services weren’t listed on the referral form.
The Hospice of Windsor and Essex County developed a new
“Hospice Services and Palliative Care Referral Form” that no longer has a
disclaimer and gives health care professionals the ability to refer to all
hospice services and programs. The new referral form is the result of our
collaboration with our hospital and LHIN stakeholders.
With the new form, clients with any PPS can be connected to
additional hospice services such as social work, a nurse consultant, spiritual
care and wellness services with the exception of the Palliative Medicine
Program if they have a life limiting diagnosis.
Although the number of individuals dying before being seen
was reduced, there was an increase in the number of urgent referrals, which is
both a positive and negative outcome. It is negative because clients are being
referred to palliative care late in their trajectory, but positive because the
number of referrals from the hospital have increased throughout our project and
not just from the oncology unit where we initially targeted.
Our wait time has actually decreased since the
beginning of this project. The team has begun to work more effectively with our
partners (e.g. oncologists/hospitalists).
Our next steps include:
- Providing education to physicians and LHIN Care
Coordinators about the project and expected outcomes
- Holding an education night with the oncology
team and the Windsor Regional Cancer Centre to review the criteria for the Palliative
Medicine program and tour our residential homes.
- Expanding the use of our referral form beyond
our pilot floors to include community and other hospital campus sites.
hospice education for health care professionals regarding our services. This
education will touch on primary care physicians and clinics as well as
hospitalists and emergency room physicians.
- Reviewing patient experience through surveys and
We realized early on that working in isolation was not going
to improve access to palliative care services in our region. We needed to work in partnership with our
stakeholders and include them at various points throughout the project to
gather their feedback and buy-in.
It was important for us to engage with physicians and
involve patients. We kept the scope manageable and tried to avoid making
assumptions. Using quality improvement tools such as the fish bone diagram and
pareto chart helped us focus on concrete data to make good decisions.
For full details on this IDEAS project, click
. To listen to a webinar about this project, click
You may also be interested in:
The Palliative Care Implementation Support Community of
Practice on Quorum
This community of practice is part of a larger effort to
support the implementation of the new Quality Improvement Plan (QIP) indicator
that focuses on the early identification and assessment of patients who might
benefit from the palliative approach to care.
Gain access to tools and resources; information about
upcoming support sessions; and opportunities to engage with colleagues across
other organizations and sectors.
Steps to join:
- Create your Quorum account.
- Visit the Palliative
Care Implementation Support Community of Practice
and click the “Join