Transcript Presentation Slides Part 3

End of Life – Part 3
Learning Session 1
Presenter’s name here
Location here
Date here
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
2
Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
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Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
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Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
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Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
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Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
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$1,540.18
$160.00
Collaborating with Your Local Team
(35 minutes)
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Objectives
 Who is on the local Primary Care
Team?
 What does primary care team
collaboration look like?
 Working with
 Home and Community Care
 Specialty palliative care team
 Non-palliative consultants (specialists)
 Local resources + CHARD
reference
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Who is the patient’s care team?




Patient, family and informal network
Family physician
Community pharmacist
Home Health / Community Care –
 Nurses/rehab/home support
 Nurse practitioners, community RT
 Disease specific consultants / services
 Hospice palliative care consult teams
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Spectrum of collaboration
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Transitions in life-limiting illness
Early
Chronic Disease
Management
Hope for cure
survivor
Decompensation
Disease advancement
experiencing life limiting illness
Complication indicators
Seniors at risk
Dependency and symptoms
increase
PPS
ESAS
Home care
BC Palliative benefits
Transition 1
Transition 2
Transition 3
Time of
Diagnosis
Time
McGregor and Porterfield 2009
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Decline and last days
Transition 4
Death and
bereavement
Transition 5
Transitions in life-limiting illness
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Content of EOL Algorithm ‘Roles’
 End of Life Roles – Transition
 Key indicator for the transition
 Reference documents for that transition
 Roles of MOA
 GP
 Specialist
 Home & Community care – case manager, care
coordinator, or home care nurse
Family, informal caregivers and volunteers
have key roles in care
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Working together GP and Home and Community
Care?
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Transition 1
Advancing Disease
Would not be surprised if pt died in next year
– Discuss goals, wishes & plans as illness advances. Initiate
advance care planning.
– Identify other involved providers & ensure information
exchange.
– Medical assessment of patient symptoms, needs &
supports.
– Consider referral - Chronic disease clinics. Home and
Community Care if functional status declining and home
based supports needed.
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Transition 2
Decompensation
Prognosis months versus more than a year;
cancer – PPS 50%
Focus on Integrated Care Planning & Coordination with
Home and Community Care




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Coordination of care conversation: GP and HCN.
Enable ready access to achieve co-provision of care vs
parallel practice.
Assess needs and develop plan
Tools – BC Palliative Care Benefits application (drugs & HCN
assessment); GP letter
from Home Health
Criteria for BC palliative benefits
 Criteria is both prognosis and needs based
 Last months of life versus years (approx 6 months)
 Functional decline. (PPS 50%)
 Accepting of palliative focus of services.
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Transition 3
Dependency and symptoms
• Increased frequency of team communication.
• HCN & GP connecting as are anticipating changes,
responding to acuity, preparing patient & family for changes
and death.
• Identify goal and backup – home death or
hospice/hospital.
• GP home visit – ideal in conjunction with HCN; plan for 24
hr access to support for patient/family.
• Tools – palliative care planning conference; No CPR order;
preparation for time of death; may complete Notification of
Death form.
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Transition 4
Last days
 Responsiveness / plan required – anticipating dying – may
be change in plan for home death.
 Nurse and physician: Reinforce family preparation what to
expect prior to death and at time of death.
 Anticipate route changes, meds for active dying.
 Clear plan who to call for what 24/7.
 Complexity – HPC consult.
 Tools – medication kits; Notification of Expected Death
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What are the Hospice Palliative consult services
available across transitions?
 HPC specialists: (Physician, nursing, psychosocial) available in your
community
 After hours and weekends in your
health authority and community.
Fraser East and Langley:
Fraser North:
White Rock:
Fraser South:
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1-888-757-2915
604-450-3247
604-450-1639
604-450-1800
Victoria Hospice (main):
250-370-8715
Vancouver
604-742-4010
BC: areas with no local
consultation service
(MD to MD calls only)
1-877-711-5757
When to refer to HPC specialist: Indicators
 Complex patient / family needs or
anticipated illness course.
 Distress with symptoms or coping
remains
 No resolution within 2-3 interventions.
 Distress continuing.
 Complex family dynamics and indications
of total pain.
 Self reflection - knowledge, skill and
ability of involved team in relation to
patient/family needs.
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Specialist-GP shared care
• Communicate:
• relevant patient-specific information
• family issues if relevant.
• Clarify early in Specialist-GP relationship:
• roles in care of patient through transitions of Chronic
Disease Management
• needs, expectations and outcomes from the consultation
• Indicate lines of communication/availability to share
care effectively.
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Identification of Patients who may benefit from
Palliative Approach
 Surprise question
 Die of illness where you are providing consultation?
 Die of comorbidities?
 Choice or need for comfort care
 Clinical indicators
 Sentinel events
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Specialty Practice and EOL
• If palliative approach appropriate:
• reflect in treatment recommendations
• give GP permission/advice about stopping medications.
• Inform patient/family
• All options including palliative care with no active treatment
• realistic outcomes of treatment options
• Give patient “My Voice”:
• follow up with yourself &/or family physician
– include in communications to GP
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Specialty Practice and EOL
 Shared care through end of life
 Include recommendations for disease specific
symptom management as patient approaches
end of life.
 Indicate availability for access to advice as
patient enters 4th transition to support GP in the
care of patient at end of life. (telephone fees
available to both to support)
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Telephone fees to support GP-Specialist Shared care at
EOL
• Urgent advice needed (< 2 hours)
– Specialist fee G10001
– GP with Specialty training fee G14021
– GP requesting urgent advice fee G 14018
• Less urgent advice (up to 1 week)
– Specialist fee G10002
– GP with Specialty training fee G14022
– GP requesting advice as part of Community Patient
Conferencing (patient lives at home or in assisted
living) fee G14016 – can also include discussion of
management plan with Home Care Nurse or other
AHP – per 15 minutes or greater portion.
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A web-based directory of specialists and services,
containing detailed referral information to help you locate
appropriate and available resources for your patient
Over 26,000 referral resources at your fingertips

Health authority & other publicly-funded services

Private, fee-based services

All specialist physicians

A variety of allied health professionals
Improve your referral efficiency and effectiveness

Cut down on the time & frustration finding the right resource for patients

Access relevant, detailed and organized information to ensure appropriate and
complete referrals to the right provider
Built by and for physicians

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An initiative of the General Practice Services Committee (GPSC), operated by
HealthLink BC, with input from physicians & MOAs
Table discussion
Think about your practice in relation to the
palliative approach:
 How can you more effectively work as a team
with these patients?
 How can you support one another?
 What could you do differently to maximize
the roles and time of all primary providers?
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Collaborative practice: Table discussion
Identify one aspect of
care that you will do
differently in your
practice and when
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