Collaborating with Your Local Team

1. Collaborating with Your Local Team (35 minutes)

2. 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

3. 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

4. Spectrum of collaboration • Parallel practice • Consultation/referral • Co-provision of care

5. Transitions in life-limiting illness Early Chronic Disease Management Hope for cure survivor Seniors at risk Decompensation experiencing life limiting illness PPS ESAS BC Palliative benefits Disease advancement Complication indicators Dependency and symptoms increase Home care Death and bereavement Decline and last days Transition 1 Transition 2 Transition 3 Transition 4 Transition 5 Time of Diagnosis Time McGregor and Porterfield 2009

6. Transitions in life-limiting illness

7. 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

8. Working together GP and Home and Community Care?

9. 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.

10. 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

11. 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.

12. 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.

13. 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

14. 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 Vancouver 604-742-4010 BC: areas with no local 1-877-711-5757 consultation service (MD to MD calls only) 14

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. A web-based directory of specialists and services, containing detailed referralinformationto 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

22. 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

23. Identify one aspect of care that you will do differently in your practice and when Collaborative practice: Table discussion 23