Health Quality Ontario’s Palliative Care Quality Standard summarizes best practice for adults with progressive
life-limiting illness, including symptom control, communication about goals of
care and managing declining health. A knowledge gap in any of these areas
may contribute to unnecessary hospitalizations as well as unsatisfactory
end-of-life experiences. However, without
supplementary training, expertise and/or resources, long term care (LTC) homes
can struggle to implement changes to attain these standards.
In 2017, the Toronto Central LHIN launched the Palliative
Approach to Care in LTC (PAC- LTC) Initiative. This three year initiative aims to
strengthen the palliative approach to care in LTC homes. The overall objectives include:
- Increased communication and understanding of the palliative
approach to care.
- Enhanced resident and family satisfaction with their care
experience.
- Improved confidence and skills of LTC staff members, to be
catalysts for organizational change in delivering excellent palliative care.
The PAC-LTC initiative uses a capacity-building approach and
offers each home:
- Education on best practices in palliative care, through Pallium
Canada’s LEAP training, custom in-service education and educational webinars.
- Quality improvement (QI) training to build an understanding
of QI methodologies via the IDEAS Program and with the support of a Health
Quality Ontario coach.
- Clinical coaching from PAC-LTC coaches as well as trained
palliative care experts (nurses, physicians, social workers) working in the
homes and through a community of practice.
- Palliative care resources and QI tools to assist homes to
implement change.
When homes start with PAC-LTC, they begin with varied
knowledge and experience in the provision of palliative care. When homes complete the program, they have a designated
in-house palliative lead, an active palliative committee and an engaged
family/resident council. With support from their PAC-LTC Clinical Coach
from Sunnybrook Health Sciences Centre or Michael Garron Hospital, each home
completes a palliative care assessment and embarks on an individualized QI
project. The homes engage in self-directed PDSA cycles, determine their own
success criteria and collect their own data. Examples of the QI projects
tackled by our homes include:
- Implementation of the Palliative Performance Scale (PPS)
- Wide-spread education about palliative care
- Development and use of new documentation tools for detailing
residents’ end-of-life wishes
- Incorporation of comfort rituals to support loved-ones
- New methods to memorialize deceased residents
The success of this initiative stems from each LTC home
taking responsibility for identifying an area for improvement in palliative
care and driving their own QI agenda. Expert coaching has been important to
provide customized assistance to the LTC homes to translate their QI ideas into
better care for residents.
When asked to identify challenges in their QI projects, the
LTC homes told us that ‘comfort with new ideas’ has been problematic: there may
be a reluctance among healthcare providers to engage in end-of-life
conversations, some staff have concerns over new pain management practices, and
there can be reluctance to break down some of the traditional silos in
providing care. Further feedback from
the homes in the first year told us that the LEAP LTC education was invaluable
in offsetting these issues. With
additional funding from the Toronto Central LHIN, we were able to provide extra
LEAP LTC education sessions in spring 2019. The two-day course not only
provides up-to-date information, but it rekindles the learners’ passion for
palliative care.
One key lesson for any LTC home aiming to improve their
palliative care is to involve staff as well as regulated healthcare providers
in their planning. It is vital to
include personal support workers, activation staff, dietary aides and cleaners
as they spend significant time with residents and are alert to changes in
residents’ health. Moreover, making the
project interdisciplinary makes sure that palliative care becomes “everyone’s
business”.
The PAC-LTC initiative hopes to work with all 36 homes in
Toronto Central LHIN. Cohort 1 homes,
listed below, completed their work in November 2018. We are currently working with eleven LTC
homes in Cohort 2 and they will finish their work in November 2019. We anticipate working with Cohort 3 homes
starting in the fall of 2019.
For more information about this initiative, please add a
comment below or reach out to me at
Anna.speke@sunnybrook.ca