Download Document

Collaborating with Your Local
Team
(35 minutes)
1
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
2
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
3
Spectrum of collaboration
 Parallel practice
 Consultation/referral
 Co-provision of care
4
Transitions in life-limiting illness
Early
Disease
advancement
Decompensation
Experiencing life
limiting illness
Transitions
Transitions
Decline and
last days
Dependency and
symptoms increase
Transitions
Transitions
Death and
bereavement
Transitions
Time of
Diagnosis
Time
McGregor and Porterfield 2009
5
Transitions in life-limiting illness
6
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
7
Working together GP and Home and
Community Care?
8
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.
9
Transition 2
Decompensation
Prognosis months versus more than a year;
cancer – PPS 50%
Focus on Integrated Care Planning & Coordination with
Home and Community Care
 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
10
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.
11
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.
12
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
13
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: 1-888-757-2915
Fraser North:
604-450-3247
White Rock:
604-450-1639
Fraser South:
604-450-1800
Victoria Hospice (main): 250-370-8715
VCH + BC:
1-877-711-5757
14
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.
15
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.
16
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
17
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
18
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)
19
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.
20
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
 An initiative of the General Practice Services Committee (GPSC), operated by
HealthLink BC, with input from physicians & MOAs
21
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?
22
Collaborative practice: Table discussion
Identify one aspect of
care that you will do
differently in your
practice and when
23