Transcript Hospice Palliative Care Nurse Practitioners (HPC

Collaborating with Primary Care
CCAC NP/RRN Services
Primary Health Care Forum
October 2016
Laurie French, Senior Manager, Clinical Support & Utilization
Andrea Campbell, Nurse Practitioner, Manager, Clinical Services
South East Community Care Access Centre
Presenter(s) Disclosure
South East Community Care Access Centre
Laurie French
Andrea Campbell
Relationships with commercial interests: Nil
Grants/Research Support: Nil
Speakers Bureau/Honoraria: Nil
Consulting Fees: Nil
Potential for conflict(s) of interest: Nil
SECCAC
Direct Care Nursing Services
• Funding to CCACs since 2012 for 3 Direct Care Nursing
Services:
• Hospice Palliative Care Nurse Practitioners (HPC NP)
• Rapid Response Nurses (RRN)
• Mental Health & Addictions Nurses in Schools (MHAN)
• One local program:
• Nurse Practitioner/Nurse Led Outreach Team (NLOT)
• Also funded for Palliative Pain and Symptom Management
Consultants, and Palliative Educators
• Consideration to provincial consistency and several
performance metrics
• Focus on complex transitions to home, and hospital avoidance
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Rapid Response
Nurse (RRN) Program
• To reduce rehospitalization and avoidable emergency
department visits by improving the quality of
transition from acute care to home care for two
population groups:
• Frail adults and seniors that are medically
complex or have chronic diseases that tend
towards frequent hospitalization including:
CHF, COPD, Diabetes, Mental Health and
Behavioral Issues, Other complex/chronic
Conditions
• Medically complex/vulnerable children, and
their families
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RRN Eligibility & Referrals
• Assessed by CCAC Care Coordinators, target patients are
high risk, medically complex/vulnerable patients frail adults, seniors and children who may:
• Poly-pharmacy (e.g. more than 3 medications for
multiple chronic diseases)
• Repeat hospital admissions or ER/Urgent Care visits
• Assessed to have a brittle or poor support network
• Chronic disease exacerbations
• Referral sources now include:
• Hospital ER and inpatient departments
• Primary Care for Complex Health Link patients NEW!
• Hospital based clinics (CHF, COPD) NEW!
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RRN Primary Care
Communication
• Home visit within 24-48 hours
• Update on patient’s acute care event and post
discharge regime, clinical assessment and medication
reconciliation
• Arrange follow-up appointment with PCP within 7 days
of hospital discharge
• When there is no PCP, support finding a PCP through
Health Care Connect/ or arrange appointment through
a walk-in-clinic
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RRN Performance
Metrics 2015/16
• Over 1200 RRN home visits provided last year
• Average Time to first visit 82% within 24-48 hours post D/C
• Average Length of stay on the program was 10.1 days
including follow-up
• All patients receive a full medication reconciliation – over
33% resulted in the discovery of a significant discrepancy
that the RRN resolved with the PCP and/or pharmacist
• Many RRN patients are not receiving CCAC services, but
some were referred for ongoing support once seen
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What will contribute to
shared success?
• Help us identify high risk/frequent admission patients
(not always the traditional CCAC referral)
• Access to hospital discharge summaries/Best Possible
Medication History (BPMH)
• Review RRN assessment documents and medication
reconciliation report (via fax on day of visit)
• Access to F/U PCP appointments within 7 days
Make a referral to the CCAC requesting RRN for
complex HL patients
Call 310-2222 or fax to 613-544-1494
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Nurse Practitioner/Nurse
Led Outreach Team(NLOT)
• 36 LTCHs with 4146 LTCH beds in South East
• 4 Homes funded for embedded NPs - Providence
Manor, Extendicare, Helen Henderson and St Lawrence
Lodge
• Independent/municipal funding for an NP in three other
LTCHs (Rideaucrest, Fairmount, Trillium)
• Since 2012 the LHIN has funded the South East CCAC
to support LTCHs with an acute care Nurse Led
Outreach Team – now expanding to 6 NPs for all
other LTCHs
• Accessible to hospital ER and in-patient departments
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Goals of Nurse Practitioner
Care by NLOT in LTCH’s
• Diversion of avoidable ER transfers and
readmission avoidance
• Enhancement of communication and collaboration
across the system for necessary transfers to ER
• Provision of care of residents for acute and
episodic health problems or change in baseline
health or symptoms
• Capacity building with the LTCH staff to enhance
the level of care provided in the home
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NP Patient Care in LTCHs
• Ongoing promotion of the NP service with staff & Physicians
• Reducing ER transfers by responding to calls to assess and
develop a treatment plan for the resident with changing
health status or acute illness
• Assessing residents when transferred back from ER or
hospital admission, or new admission to LTC; development of
treatment plans as required
• Full scope of practice:
• complete medication reconciliation, treat dehydration/hypodermoclysis, wound
care/debridement, exacerbation of chronic conditions such as CHF, COPD, diabetes,
pain management. Physical assessment, diagnosis, prescribing, treating and
follow-up with staff, physicians, and family
• Providing point of care teaching with LTCH staff and residents
• Diagnostic testing (bladder scanner, vascular doppler
ABI,TBI)
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‘When to
call the
NP”
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Expanded NLOT Areas
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Top Ten Diagnoses
seen by LTCH NPs
• Chronic & acute
wounds/debridement
• Responsive
behaviours
• Viral URTI/influenza
• Pain issues
• Skin & soft tissue
infections
• Rashes
• Pneumonia; AE COPD;
chest infections
• CHF
• Falls
• Dehydration
*Regular use of bladder
scanner & vascular doppler
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LHIN/NLOT Performance
Metrics 2015/16
• 119 direct ER visits were diverted for LTCH residents
• 1095 individual residents received NP visits with 1292
treatment plans
• 13 admissions/hospital returns were supported
• Response rates: 99.4% within one hour to calls, and 97.7%
within 4 hours to visit (significant geography)
• CTAS scores for NP calls are rising indicating higher acuity in
LTC and appropriate calls to divert avoidable ER visits
• LHIN data showed significant decrease in CTAS 3/4/5 ER
visits for CCAC NLOT Homes
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Hospice Palliative Care
Nurse Practitioner Program
• 5 FT Hospice Palliative Care (HPC) Nurse Practitioners
• Currently 3 HPC NPs accepting referrals in the South East
(one on maternity leave)
• Goal to enrich the value of HPC delivery at home by
supporting the patient and family through their journey
• Full scope NP practice: pain management, collaboration with
Palliative care and family physicians, education to families and service
providers, mentor students, enhancing knowledge of others with advance
care planning, and work with families and patients to transition to end of
life with more ease
• Collaborate with the inter-professional care team including
home care, primary care, specialized hospice palliative
care, and community supportive care agencies to patients
living and dying in their place of choice.
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SECCAC
HPC NP
HL Areas
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HPC NP Eligibility & Referrals
Referrals accepted through the CCAC for patients who:
• Have a life limiting disease (e.g. cancer, COPD, CHF,
or end stage illness
• Be aware of their palliative care diagnosis, with a life
expectancy of 6-12 months
• Be identified as having HPC needs currently, or the
potential to need complex pain and symptom
management in the future
• Be receiving or referred for CCAC services
• Be supported by a Most Responsible Physician or
Nurse Practitioner who agrees to a Shared Care Model
with the HPC NP
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HPC NP Performance
Metrics 2015/16
• 56 Referrals received last year
• 682 HPC NP home visits were provided (Average 17
home visits per patient)
• Average length of stay on program was 75.9
• 54.3% Deceased in preferred place of death
• Now requiring Medication Reconciliation for all
referrals
• 90% referrals are Cancer diagnosis, with 10% chronic
disease (CHF, COPD, ALS or immune disorder)
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Lessons Learned and
Opportunities to Strengthen
Links to Primary Care
• Continue to promote program(s) (HPC NPs under-utilized)
• Streamline referral processes and criteria
• Continue to share Direct Care Nursing outcomes and results
of performance metrics
• Align more to Primary Care structures and processes
• Further partnerships to increase shared care opportunities
with Primary Care and increase regional capacity
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Outstanding care – every person, every day
www.southeasthealthline.ca