Download PREAMBLE - Central LHIN

PREAMBLE
On January 20th the Clinical Council of the Hospice Palliative Care Provincial Steering Committee presented and articulated the Essential
Minimum Clinical Standards for Hospice Palliative Care in Ontario (see attached). The Provincial Clinical Standards (PCS) are:
 a suite of 12 interconnected clinical standards.
 based on documents that represent broad stakeholder engagement as well as consensus and recommendations from experts in
palliative care.
 built on best and most current evidence in palliative care the critical actions and next steps articulated in the PCS will build upon the
important work already happening throughout the province.
The PCS are considered a starting point for standardization of clinical direction in the province, while enabling regional customization
and contextualization. They detail interconnected priority areas that need to be addressed in order to improve palliative care in Ontario.
The Clinical Council is an inter-professional council comprised of 11 Palliative Care clinicians with diverse and relevant palliative care skills
sets who applied for Clinical Council positions which were selected by the Hospice Palliative Care Provincial Steering Committee. The
Clinical Council was tasked with creating clinical standards related to palliative care in Ontario and did so using an evidence based
approach to articulate the most important areas requiring minimum clinical standards. This process began by developing a consensus
driven “Clinical Change Strategy” outlining an approach and highlighting key directional documents that were used as evidence to
determine the most important clinical areas. Each directional document represents consensus recommendations from experts in palliative
care and collation of evidence, and best practice. The process of developing the Provincial Clinical Standards built upon the best and most
current evidence in palliative care. Similarly, the PCS document outlines critical actions and next steps that will build upon many
components of excellent work that already exists within the province.
The attached document contains the 12 PCS outlining the critical actions, next steps and directional document for each standard. The
attachment also contains graphics that outline the interdependencies of the PCS and maps the PCS to the hospice palliative care model
outlined in the Declaration of Partnership. At this time the Hospice Palliative Care Provincial Steering Committee is circulating the Provincial
Clinical Standards to our partners with the intent of:
1. Seeking input from our partners, specifically with respect to overall direction of the PCS.
2. Fostering discussion. The PCS documents can now be used as regional and organizational tools to assess readiness to move
forward with implementing pan-Ontario palliative care standards.
Please share this document with your palliative care providers, and other relevant stakeholders. Feedback related to the PCS can be
forwarded to Deanna Bryant, Project Lead, at [email protected] or 416-971-9800 ext 3761
1/26/2015
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Title: Essential Minimum Clinical Standards for Hospice Palliative Care in Ontario
Phase One
Provincial Clinical Standards
(PCS)
PCS 1: A Regional Hospice Palliative
Care Program (Regional Program)
and structure is operational at each
LHIN with clear, transparent
accountabilities to the LHIN that
outlines health service provider
(HSP) responsibilities to stakeholders
and consumers. The Regional
Program will have standardized
clinical deliverables as outlined by
the Ministry of Health and LongTerm Care (MOHLTC) and the
Ontario Palliative Care Network
(OPCN). Patient reported outcomes
and quality indicators will drive
system change.
Critical Actions
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A transparent and inclusive process
has been or will be used to create a
Regional Program whose structure
meets regional stakeholder and
consumer needs as well as system
requirements and includes a
Regional Program Director and
unified Regional Clinical Leadership
Each LHIN develops accountability
or terms of reference (TOR)
agreements with their Regional
Program
Regional Program Directors have a
shared accountability agreement
with Regional Programs
Regional Program Clinical Leads
have standardized role descriptions
and accountability agreements with
both their Regional Program and
LHIN and with the OPCN Clinical
Council
Regional Program and
Directors/Clinical Leads develop
shared accountability agreements
with stakeholders and
consumers/community to:
o Customize & contextualize
PCSs
o Benchmark the PCS
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Next Steps
Rationale For Change
Regional Program Director roles
are created and positions filled
OPCN Clinical Council develops/creates the unified
Clinical Leadership role(s)
Regional Program Clinical Leads
are identified
Regional Programs create and
enact a regional work plan
Regional Programs create a
process to establish partnerships
with patient and family advisors
To achieve true patient
centered care (as per the
Declaration deliverables) one
agreed upon and
collaborative process of
palliative care delivery needs
to exist at each LHIN
Directional Documents:
 Recommendation 6
Residential Hospices
Working Group (RHWG)
 Declaration of Partnership
(Declaration) (p.33)
 2012 LHIN
Implementation Plan
 OHTAC Recommendation
2
Phase One
Provincial Clinical Standards
(PCS)
Critical Actions
o
Next Steps
Rationale For Change
Track and measure clinical
performance based on
standardized system
performance indicators
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PCS 2: A Regional Public Health
Strategy exists as a standard
element of each Regional Program,
which includes detailed work plans
outlining responsibilities at the
provincial, regional and local levels.
PCS 3:
a. All health service providers
receive essential Hospice
Palliative Care (HPC) training to
maintain and deliver minimum
standards of HPC
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 OPCN Clinical Council - collaboration
and partnership with Public Health
Ontario to establish provincial
palliative care public health
standards
 Regional Program – partnerships
with regional and municipal Public
Health Departments are established
 Work plans to include the
development of a Regional Public
Health Strategy
 Public education is a standard
component of Regional Program
work plans
 MOHLTC & Ministry of Training,
Colleges and Universities (MTCU)
and Regulated Health Professional
Colleges establish a method to
collaborate that connects curriculum
with practice to meet minimum
standards of HPC
 Regional Programs - unified Regional
Education Collaboratives are
 OPCN Clinical Council development and dissemination of
best practice palliative care public
health guidelines
 Regional Programs, Directors and
Clinical Leads together with public
health expertise and members of
the community, determine their
roles, develop work plans and
initiatives that meet provincial
standards
 OPCN/Regional Programs-create
alignment, and re-orientation of
existing MOHLTC Palliative Care
Initiative 3 Supporting and
Maintaining Hospice Volunteer
Visiting Programs to support a
Regional Public Health Strategy
 Regional Programs to establish an
accountability framework for
healthcare organizations and
standardized approach to staff and
clinician development
 Existing regional palliative care
educational resources (MOHLTC
Palliative Care Initiatives # 1,2, and
4) be collaboratively re-aligned as
A sustainable system
requires the community as
full partners; aging, loss and
bereavement are everyone’s
responsibility, not just health
care providers.
Directional Documents:
 Ontario Health Technology
Advisory Committee
(OHTAC)
 Recommendation 4 RHWG
Patients across the province
will receive care from health
service providers who have
all received the same
essential level of hospice
palliative care training, which
ensures quality care is
provided.
3
Phase One
Provincial Clinical Standards
(PCS)
Critical Actions
established to coordinate regional
educational needs and resources
 Pallium LEAP courses are
coordinated centrally in each region
as a deliverable of the Education
Collaborative
b. ALL specialized HPC team
providers achieve and maintain
specialty level training in hospice
palliative care and maintain
clinical practice standards
 All relevant Ontario accrediting
Colleges (i.e. OCFP, College of
Nurses, RCPSO, etc.) collaborate to
articulate, establish and deliver
professional development standards
for minimum and specialized HPC
standards
 Regional accountability for ensuring
professional development of existing
HPC teams & minimum practice
standards
c. A Health Human Resource (HHR)
strategy for hospice palliative
care specialized clinicians is
developed and implemented for
the province; this includes
physicians, nurses, nurse
practitioners and other allied
health professionals.
 Develop minimum standards of
sustainability for specialized HPC
clinician’s (see PCS 11)
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Next Steps
Rationale For Change
base for a unified Regional
Education Collaborative and
resultant work plans
 MOHLTC Palliative Pain and
Symptom Management
Consultants’ role (MOHLTC
Palliative Care Initiative 4) be realigned to include LEAP Coaches for
each Regional Program
 Regional Programs asset map
existing resources and create region
wide mechanisms towards
standards, shared deliverables and
shared resources
Directional Documents:
 OHTAC
 Recommendation 4 RHWG
 Regional programs articulate their
future steady state HHR goals based
on existing best practice models
 Province/MCTU/MOHLTC/OPCN
increase specialty level physician
training positions (fellowship
training) by an agreed upon number
and yearly increments
Directional Documents:
 OMA
 CSPCP Human resource
assessment
Directional Documents:
 OMA
 OHTAC
4
Phase One
Provincial Clinical Standards
(PCS)
PCS 4: Physician remuneration for
palliative care is standardized and
includes:
a. A new province wide, regionally
affiliated AFP for focused
palliative care practice
b. Family physician billing and fee
codes unique to primary care
support primary care engagement
in the provision of palliative care
(e.g. G512)
c. Fair, equitable and unique
billing/fee codes for all physicians
to support both palliative care
related interventions (e.g. ACP
and goals of care discussions) as
well as integrated models of
partnership and collaboration
d. Equitable funding for palliative
care groups providing hospital on
call coverage
e. Equitable funding for groups
providing community on call
services in primary level or
consultation/shared care models
f. Providers participating in a
Patient Enrollment Model (PEM)
will provide direct palliative care
to their patients
g. Primary care providers are able to
prescribe EOL medications
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Critical Actions
OPCN Clinical Council to establish and
oversee provincial physician
remuneration standards which in Phase
One include:
a. The existing “GP focused AFP in
Palliative Care” is eliminated and
replaced or provincially revised and
standardized
b. The existing Hospital On-Call (HOC)
funding structure is revised to
include acute care palliative care
consult teams on call, or a new
hospital/regional on call is developed
c. The proposed Community Palliative
On-Call (CPOC) funding to be aligned
with new provincial palliative care
standards
d. Accountability agreements and
recognition awards developed to
support FHTs, FHOs and FHGs to
deliver direct palliative care
e. The Palliative Care Facilitated Access
(PCFA) medication coverage program
is re-vamped to be:
 Fully accessible to primary care
providers for regionally rostered
palliative care patients
 Less restrictive
 Open to ongoing adjustments to
match standard of care
medications to prescribing practice
Next Steps
 With the aim of formally
collaborating to develop a unified
and sustainable regional physician
strategy, Regional Programs engage
all stakeholders with palliative care
HHR assets or deliverables to
compile an asset map of existing
resources to build unified work
plans i.e. Regional Physician
Strategy?
 The Regional Physician Strategy
includes primary care leadership
Rationale For Change
Funding models support
policy directions that
encourage primary care to
be involved in providing
palliative care to their
patients across setting of
care and in collaboration
with a specialized hospice
palliative care team when
needed
Directional Documents:
 OMA
 Recommendation 3 RHWG
 McMaster health forum
5
Phase One
Provincial Clinical Standards
(PCS)
PCS 5: Utilization of a province wide
HPC EMR connectivity platform with
the ability for patient navigation and
cross sector health service provider
access in real time
PCS 6: Values and goals-based
conversations inform advance care
planning (ACP) processes and
decision-making around consent for
standard end-of-life treatment plans
and address common end-of-life
decisions (i.e. beyond code status,
e.g. POST). Previous discussions and
decisions are accessible to patients,
substitute decision makers and
clinicians 24/7.
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Critical Actions
 Provincial level investment in vendor
with the ability to connect existing
databases and develop a P palliative
care EMR platform
 Regional development of
collaborative partnerships with
existing stakeholders and EMRs to
begin to develop a registry (see PCS
7)
 Work plans to include
implementation of standardized
system performance indicators and
data collection
 OPCN Clinical Council establishes
provincial standards for both an ACP
Conversation template & a Serious
Illness Treatment Plan
 Regional Programs oversee the
development and implementation of
ACP and Serious Illness Treatment
Plan strategies as core elements of
Regional Work Plans
 ACP Conversations are a clinical
imperative for all registry patients
 Serious Illness Treatment Plans are a
clinical imperative at the time of
admission to any facility and are
routinely revisited throughout stay
Next Steps
 Provincial HPC EMR customized
and partnered as part of the work
plan of each Regional Program
 Healthlink connections with each
Regional Program
 Data collection and management
centralized and overseen by each
Regional Program
 Registry development part of the
work plan of the Regional Program
- fostering both organizational use
and alignment towards a Region
wide registry
 Resources of Regional Program
assist with organizational registry
development
 OPCN Clinical Council to strike short
term and time limited expert panels
with the aim of recommending
tools and processes aligned with
the provincial Health Care Consent
Act and the National ACP
Framework
 The MOHLTC Palliative care
consultants’ role (PC Initiative 4) be
re-aligned to include ACP and Care
Plan Coaches for each Regional
Program
Rationale For Change
A unified, real time EMR is
essential to follow a patient
across care settings to allow
for the provision of safe care
Directional Documents:
 Recommendations 2 & 7
RHWG
 GSF
 HPC Steering Committee
Data and Performance
Working Groups
recommended indicators
Provincial standards will help
patients to begin the process
of planning for the future
and will facilitate decisionmaking when considering
consent for proposed
treatment plans
Directional Documents:
 OMA
 OHTAC
 Recommendation 7 RHWG
6
Phase One
Provincial Clinical Standards
(PCS)
PCS 7: The Gold Standards
Framework (GSF) approach of
“identify, assess and plan/manage”
and the “Palliative Approach to
Care” are operationalized by
utilizing Regional palliative care
patient registries and ongoing
components of regional work plans
PCS 8: A provincial pediatric
palliative care strategy with tertiary
care and community standards
Critical Actions
 Regional Programs and LHINs to
adopt and adapt the GSF to utilize
regionally
 OPCN Clinical Council adopts and
endorses existing Pediatric
Provincial Standards
 Implementation of Inter-Regional
Nurse Practitioner Mentor model
Next Steps
 Registry development intra and
inter-agency and cross sectorially
 The MOHLTC Palliative care
Consultants role (PC Initiative
funding number 4) be re-aligned to
include GSF Coaches for each
Regional Program
 Resources of Regional Program
assist with organizational registry
development which includes the
care team level
 Registry development is part of the
work plan of the Regional Program
- fostering both organizational use
and alignment towards a Region
wide registry that meets patient
and community needs
 Pilot project involving engaged
LHINs to proceed
 Regional application of the
provincial strategy as part of
Regional Program work plan
Rationale For Change
Early identification, evidence
based assessment and
management across a
patients journey is the
international person centred,
sustainable and cost
effective best practice
Directional Documents:
 OHTAC
 Recommendation 1 RHWG
 McMaster health forum
Children and their families
need access to palliative care
too. The provincial strategy
will provide increased equity
and access to palliative care
for pediatric patients and
their families in their own
local community as well.
Directional Documents:
 Declaration
 Recommendation 1 RHWG
 CHPCA
 POGO
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Phase One
Provincial Clinical Standards
(PCS)
PCS 9: An Aboriginal Palliative care
strategy for PC community
development
PCS 10: The Palliative Approach to
care is a standard component of
each primary care practice as well as
primary level providers’ practice
1/26/2015
Critical Actions
 The Kelley Community Capacity
Development model for PC is
adopted by each Regional Program
 Regional Programs are tasked with
realigning, reorienting and
consolidating resources to enable
development of the Palliative
Approach to care as a regional
standard and deliverable
 Regional Programs will foster and
enable consultative and shared care
models. Substitution models of care
should be a limited resource, based
on case complexity and only exist as
a result of an agreed upon process
that is contingent on a regional work
plan
Next Steps
 Each Regional Program in
partnership with First Nations, Inuit
and Metis oversees the
implementation of their Aboriginal
Palliative care strategy
 Regional Programs develop formal
linkages between specialized HPC
teams and primary care as a
standard component
 Regional Programs to establish 24/7
access of specialized HPC teams to
primary care
 Realignment of existing funding for
Palliative Care Consultants
(MOHLTC Initiative #4) to Regional
Program to support registry
developments and navigation
 Realignment of the MOHLTC
Palliative Care Nurse Practitioner
program to Regional Program to
support 24/7 both primary care and
specialized HPC teams in support of
patients on regional registries
 Registry development in practices
and across regions
Rationale For Change
First Nations, Inuit, and
Metis need equitable access
to culturally safe palliative
care services in the setting of
choice.
Directional Documents:
 OHTAC
 Recommendation 2 RHWG
 Recommendation 3 RHWG
 Kelley report
To meet the societal
palliative care needs of an
aging population, basic or
primary level palliative care
needs must be addressed by
clinicians other than
palliative care specialists.
Ideally primary care teams
will provide most of this care
but we also need oncology,
cardiology, nephrology, etc
teams to be providing some
of the basic palliative care as
well
Directional Documents:
 Recommendation 3 RHWG
 OHTAC
 2012 LHIN
Implementation Plan
8
Phase One
Provincial Clinical Standards
(PCS)
PCS 11: Specialized HPC teams
follow patients within and across
care settings from first identification
to bereavement and are adequately
developed and resourced across
each LHIN to support patients and
primary providers
1/26/2015
Critical Actions
 Regional Programs realign resources
from organizations that currently or
should provide HPC across sectors to
create comprehensive specialized
HPC teams with shared
accountability. This includes
willingness to realign current
resources including home and
community care.
 Regional Programs to outline a
process for HPC teams to be a shared
deliverable for the region. Cocreated and collaborative
accountabilities are shared among
LHIN leadership, Regional Program,
hospitals, CCAC
 OPCN Clinical Council - articulates
guidelines for a standard of:
a. All specialized HPC teams as
teaching teams
b. Capacity building
c. Mentorship
d. Team deliverables
e. Team meetings for registered
patient care planning
f. Bereavement care
g. Care for the caregiver
 OPCN will identify and address
existing legislative and policy barriers
that inhibit the implementation of
cross sector specialized HPC teams
Next Steps
 Regional programs create planning
groups with relevant stakeholders
 Mechanisms created at the regional
level to involve primary care leaders
in collaborative planning
Rationale For Change
Patients, families and
primary level providers have
told us they want equitable
access to specialized
palliative care when needed
and evidence tells us HPC
teams are best practice.
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Directional Documents:
 Recommendation 3 RHWG
 OHTAC
9
Phase One
Provincial Clinical Standards
(PCS)
PCS 12: A standardized population
based approach and comprehensive
plan for regionally appropriate
settings of care will be utilized. This
includes appropriate resources for
home deaths and resources for an
appropriate mix of residential
hospice and tertiary palliative care
beds. Home care resources and
funding are organized to follow the
patient across settings of care.
Critical Actions
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OPCN Clinical Council:
o Define and articulate
provincial standard for bed
types including palliative
care units (PCUs) other
acute care and chronic
care/LTC beds and
residential hospices
Provincial Standards are
established for funding and staffing
of acute PCUs and residential
hospices
Palliative Care related Quality
Based Procedures (QBPs) are
developed that include interprofessional teams for all diseases
(including heart, lung, renal and
neurological), applicable across the
illness trajectory and not just at the
end of life.
Regional Programs leverage patient
centered Community Hubs that
inform, educate and support
informal caregivers and create
clinical communities of practice for
health service providers
Regional programs support
realignment of home and
community care resources and
funding for patients receiving
palliative care
Development of funding models to
Next Steps
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Provincial - performance
indicators for PCUs are fine tuned
to better represent both the
patient populations on these units
and the role of the PCU
Provincial - residential hospices
are 80% funded
Regional - gaps in existing acute
PCUs and residential hospices that
prevent meeting provincial
standards are addressed as part of
regional program work plans
Develop a policy that will ensure
the implementation of the
“Expected Death in the Home
(EDITH)” protocol across Ontario.
This will facilitate death with
dignity and prevent the
performance of CPR on persons
receiving palliative care who are
expected to die.
Rationale For Change
A sustainable system
requires the right mix of
resources across care
settings to meet patient
needs
Directional Documents:
 Recommendations 1, 3, 5
RHWG
10
Phase One
Provincial Clinical Standards
(PCS)
Critical Actions
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Next Steps
Rationale For Change
“follow the patient” to provide
equal access to service whether at
home or in an institution. (eg in
addition to home care; access to
medications, transport services for
tests/investigations)
Define parameters of home care
services based on clinical pathways
that incorporate clinical, functional
and psychosocial needs of the
patient and caregiver.
Directional Documents
 2012 LHIN Implementation Plan Letter from Hospice Palliative Care Provincial Steering Committee Co-Chairs
 Advancing High Quality, High Value Palliative Care in Ontario: A Declaration of Partnership and Commitment to Action 2011 (The
Declaration)
 Canadian Society of Palliative Care Physicians Human Resource Assessment
 Gold Standards Framework (GSF)
 Hospice Palliative Care Steering Committee’s Data and Performance Working Group Recommendations
 Community Capacity Development in Palliative Care: An Illustrative Case. Study in Rural Northwestern Ontario
 McMaster Health Forum Citizen Brief: Improving Access to Palliative Care in Ontario
 McMaster Health Forum Panel Summary: Improving Access to Palliative Care in Ontario
 Ministry of Health and Long-Term Care Palliative Care Initiative
 Ontario Health Technology Advisory Committee (OHTAC Recommendations)
 Ontario Medical Association End of Life Care Strategy
 Report of the Paediatric Palliative Care Work Group October 2011
 Residential Hospices Working Group Report (RHWG)
1/26/2015
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Essential Minimal Clinical Standards for Hospice Palliative Care in Ontario
System &
accountability
The public
Clinicians
PCS 1. REGIONAL PROGRAMS
PCS 2. PUBLIC HEALTH STRATEGY
PCS 3. PROFESSIONAL DEVELOPMENT & EDUCATION
PCS 4. PHYSICIAN WORKFORCE
Tools to
improve
direct care
Direct care
(Teams & settings)
1/26/2015
PCS 5. E-HEALTH & TECHNOLOGY
PCS 6. ADVANCE CARE PLANNING & END-OF-LIFE TREATMENT PLANS
PCS 7. GOLD STANDARDS FRAMEWORK - REGISTRIES
PCS 8.
PAEDIATRIC CARE
PCS 9.
ABORIGINAL CARE
PCS 10.
CAPACITY BUILDING:
PRIMARY LEVEL
PCS 11.
HPC CONSULTANT
TEAMS
PCS 12.
RESIDENTIAL HOSPICES &
PALL CARE UNITS
12
Inter-Relationships and Dependencies among the 12 PCS
10
# this PCS IS NEEDED BY
# this PCS WOULD SUPPORT
# this PCS COULD USE THE SUPPORT
# this PCS NEEDS
8
6
4
2
0
1
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2
3
4
5
6
7
8
9
10
11
12
Each PCS relates in some way to each of the other 11 PCSs - this is a visual representation of these relationships
The vertical axis represents the number of other PCSs and the shading represents one of four relationships
For each PCS, the darker the shade the more so this PCS is needed by other PCSs
For each PCS the lighter the shade the more so this PCS needs other PCSs
1/26/2015
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PCS Mapped to the HPC Model from the Declaration of Partnership
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