Residents at the end-of-life are not consistently identified in a timely manner. Advanced care planning is frequently not in place, and goals of care are not clearly stated and consistently reviewed.
Multiple unnecessary transfers (from LTC homes) leading up to end of life; resident may end up dying in the hospital.
This IDEAS team had the following project level aim:
By Oct 31, 2018, 50% of identified end of life residents will have their Advanced Care Plan and goals of care identified, documented and reviewed regularly by both participating LTCHs.