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Preventing unnecessary transfers from long-term care to hospital just makes sense –- it’s better for residents and for the health care system. William Osler Health System’s award-winning Preventionof Error-based Transfers (PoET) Project, developed by Dr. Jill Oliver, Health Care Ethicist, and Dr. Paula Chidwick, Director of Research and Corporate Ethics, finds that one good way to reduce error-based transfers is to change how long-term care homes, residents, and caregivers understand consent, capacity, and substitute decision making. The project has been very successful in the Central West LHIN and is now expanding to the Mississauga Halton LHIN and the Hamilton Niagara Haldimand Brant LHIN.

Health Quality Ontario sat down with Dr. Jill Oliver, Lead of the PoET Project and a Health Care Ethicist in William Osler’s Ethics Quality Improvement Lab, to discuss the development of PoET, its goals, and the work to spread this project.

Jill, can you tell us a little bit about PoET?

The PoET Project is an ethics quality improvement project that aims to reduce consent-related errors in long-term care homes, and the transfers to hospital that can follow.

PoET has been developed through close collaboration with staff, physicians, residents, and family members from long-term care. By participating in PoET, long-term care homes make a commitment to change decision-making habits and practices in order to align with Ontario’s patient-centered Health Care Consent Act.

The work began in 2012 and the evolution of the project can be found on our website.

The project launched in the Central West LHIN, and once we reached about 50% participation among the homes in the LHIN, we turned to spreading the project. In the Central West LHIN, I was able to visit long-term care homes and work directly with their teams. But it wasn’t feasible to have me flying all over the province. That’s when we developed our provincial training program.

Can you tell us about the PoET training program?

The first cohort began in the fall of 2018. Long-term care homes participated in two workshops over two days, and then monthly teleconferences were held with each home to check in and assist with the changes they were making and challenges they were having.

Through the workshops, long-term care home staff and physicians learn about the Health Care Consent Act, change ideas, adaptive challenges, change management, and professional obligations. At the beginning of the training program each home develops measures that make sense for them depending on the changes they intend to make, and then we work with them to develop ways of collecting data, reviewing it, and making changes based on what they see.

The second cohort will be starting September, 2019. We’re looking forward to sharing our cohort’s results as they complete the training program and implement their changes.

What do the long-term care homes learn?

One thing the homes learn is how to notice places where the Health Care Consent Act is not being closely followed, and then how to change this. For example, right now there is a big myth – that capacity is all or nothing. And what is sometimes called “level of care forms” or “advanced directives forms” are some of the worst tools for continuing this myth.

We help homes to change beliefs and behaviours so that they can stop using those forms – if they do currently use them – and encourage alignment with the Act. So we might ask a home – do your staff treat capacity as something that is decision- and time-specific? If not, why not? What changes need to be made so that staff will be encouraged to treat capacity as something that comes and goes? What changes can be made to discourage treating capacity as if it’s all or nothing?

Capacity is messy. A resident’s ability to make decisions comes and goes, and this ability is decision specific. Some residents are completely able to make some decisions, while not able to make others. A resident’s capacity should be evaluated in the moment and should depend on the treatment being considered. For example, a resident might be capable of making a decision about pain medication, and at the same time, be incapable of making a decision about surgery.

How does the training program shift how long-term care homes understand consent and capacity?

We start with data. For homes that are currently using a level of care form or advance directive form, we encourage the use of a tool called the “Individualized Summary” at admission. This tool asks residents about their values and beliefs around their care rather than asking them to make end of life decisions at admission. If the resident is then unable to make a decision, this form brings their voice to the table. It’s not used for decision making on its own, but instead gives the substitute decision maker the information they need to interpret what the resident would want.

Ideally, we support the phasing out of levels of care forms and advance directives forms as part of the adoption of PoET, but even when institutional policy requires those forms, we still support organizations to increase the ways they can change behaviour and practice to align with the Health Care Consent Act.

Have you seen any barriers to organizations aligning better with the Health Care Consent Act?

it is challenging to bring everyone alongside these changes, especially if they perceive the changes to be risky.

Within the Act, a lot of the mechanisms that exist to protect residents’ rights begin and end with the physician – so implementing PoET can sometimes mean great changes for physicians. I think physician resistance is often well-meaning – they want to avoid conflict (especially with caregivers and family members), or they don’t recognize some of the necessary elements as part of their role, or they see the changes as requiring them to take on risk.

But the model of consent defined by the Act is ultimately better for patients and physicians. And so we work with organizations on change management and encourage broader participation in the program and its work.

What success have you seen with PoET over its evolution?

Since PoET started we have been tracking the number of long-term care residents who died in hospital and were sent there two or more times in the two-month period prior to death. We knew when we started this work that there was a group of long-term care residents who were sent to the hospital multiple times before dying there – and we believed that the residents in this group in particular would benefit from a reduction of consent-related errors. Over the years this number has been reducing, and our most recent data shows that there has been a 68% decrease since 2012.

Do you have advice for organizations considering PoET or something like it?

Change can be hard. And making these changes can be a huge challenge. But in the end, things will be better and easier for everyone, including – obviously – residents. Reminding people why you are changing, and that the changes are designed to encourage alignment with the law and professional obligations, can often help bring them along.

How should people get in touch if they want to learn more about PoET?

The website poetproject.ca is a great place to start and you can contact Jill.Oliver@williamoslerhs.ca.

Do you work in long-term care?

Visit Quorum’s Indicators & Change Ideas page for more information on potentially avoidable emergency department visits.

You may also be interested in our quality improvement stories featuring the work of long-term care homes across Ontario.