The CHCA is documenting and disseminating five leading practices that facilitate the building of operational excellence in home-based palliative care in Canada. The interventions were identified at the 2018 Home Care Summit and reviewed for applicability by a panel of home care leaders.

These High Impact Practice initiatives were chosen with the purpose of impacting home-based palliative care and the healthcare by:

  • Promoting home care that provides evidence-informed service delivery directed toward the achievement of health outcomes in the setting that best support the individual and family.
  • Enhancing the effectiveness of home care.
  • Raising the awareness of ways that home care contributes to an effective health care system.
  • Mitigating rising healthcare costs and accentuate existing resources and expertise.
  • Enabling sharing and transferring of knowledge, expertise and experience through networking and peer-to-peer learning.

Whole Community Palliative Rounds

An innovative approach to inter-professional communication, shared decision-making and rapid clinical problem-solving for symptom burden in high-risk individuals who require palliative care services. Whole Community Palliative Rounds is a strategy to enable rapid clinical problem-solving for symptom burden in high-risk individuals, purposeful and timely communication, shared decision-making and collaborative care planning among members of an inter-professional care team.

This High Impact Practice showcases how Interior Health in British Columbia has successfully implemented this strategy

Rural Palliative Care In-Home Funding Program–Calgary Zone

An augmented service model in rural Alberta that is supporting clients nearing end of life to stay at home when desired, while ensuring they receive the required additional care. While rural Canada makes up 95% of the country’s landmass, it accounts for less than 20% of the population. Home care programs across the country are challenged with providing responsive, high-quality services to individuals residing in rural communities

This High Impact Practice showcases an augmented service model in rural Alberta that is supporting clients nearing end of life to stay at home when desired, while ensuring they receive the required additional care.

The INSPIRED COPD outreach programTM

This High Impact Practice showcases how the INSPIRED Program was enhanced to provide social supports and advance care planning for individuals with advanced COPD benefit from an integrated palliative approach to care. Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in Canada and the leading cause of adult emergency department visits and hospitalizations for chronic illness.  While COPD cannot be cured, individuals with advanced COPD benefit from an integrated palliative approach to care.

This High Impact Practice showcases how the INSPIRED Program was enhanced to provide social supports and advance care planning throughout an individual’s illness trajectory.

Virtual Palliative Care Intervention

An innovative model that combines an app for early identification of symptoms with videoconferencing to help support palliative care patients in the community. Software applications (apps) are providing health care professionals with opportunities to integrate technology into clinical practice.

This Virtual Palliative Care Intervention showcases a pilot study of a model that combines an app for early identification of symptoms with videoconferencing to help support palliative care patients in the community.

OPERATIONAL INNOVATIONS

As part of a pan-Canadian initiative, the CHCA selected organizations who have leading practices in the project four key areas. The following successful innovations were presented at the 2018 CHCA Home Care Summits.

ADVANCE CARE PLANNING

Access to Advice and Advance Care Planning – An Edmonton Perspective – Advance Care Planning/Goals of Care, the collaboration with Community Emergency Medical Services with an Assess Treat & Refer program, and new ways of accessing technology and caregiver feedback will be presented. Download Presentation

Utilizing Interpreters to Support Culturally Sensitive Goals of Care/ Advance Care Planning Discussions – An interactive online course that helps interpreters critically reflect on their interpretation of the questions in the Serious Illness Conversation Guide. Download Presentation    |    Watch video

Responding to Policy Issues: How a Provincial Advance Care Planning/Goals of Care Designation Community of Practice Promotes Excellence – The development of a provincial ACP/GCD Community of Practice, a centralized meeting place for ACP champions to share, learn, and interpret the provincial policy and procedure. Download Presentation     |     Watch video

Rural in-Home Palliative Care Program- Components and principles of an innovative rural funding model to augment in-home palliative care services. Presentation PDF       Watch video

Integrating a Palliative Approach to Care by Having Conversations Early (IPACE)- Facilitating early conversations using Ariadne Lab’s Serious Illness Conversation Guide (SICG) or other conversation tools to respect individual’s these wishes regardless of the setting of care and to foster this change in practice as part of the clinician’s daily work. Presentation PDF    Watch video

Advance Care Planning Framework – An advance care planning framework that provides guideposts and reinforces the continuous and progressive process of conversations with family, friends and health care provider(s). Presentation PDF     Watch video

ASSESSMENT AND DELIVERY

Telepalliative Care – Co-designed with the Ontario Telemedicine Network this virtual approach to palliative care supports timely symptom assessment for adults across the region who prefer to receive care in their home. Presentation PDF          Watch video

Integrated Palliative Care Approach in Home Care – The integrated clinical care delivery approach is a shared model integrating the Extra-Mural Program (EMP) and the Residential Hospice (RH) – privately owned and operated by the community hospice association, primary care and other community resources. Presentation PDF    Watch video

Virtual Palliative Care: Right Patient, Right Time, Right Place, Right Care – The RELIEF (Remote self-reporting of symptoms by patients) application allows for patients with palliative care needs to self-report their symptoms daily, in their homes, using electronic standardized assessment tools. Their status is monitored in real time and thus allows for more timely and appropriate responses by health care providers.  Presentation PDF       Presentation and video

Continuum of Care for Clients with Advanced Heart Failure (HF) – A collaborative clinical partnership for home nursing involvement and follow-up for individuals with advanced heart failure to recognize and rapidly treat exacerbations in the home.   Presentation PDF        Watch video

EQUIPMENT AND MEDICATION

End-of-Life Symptom Management Kit for use at Home in Rural Northwestern Ontario – Designed using best practice and evidence-based research, this is a standardized palliative symptom management kit which includes necessary medications and medical supplies required to treat the most common end-of-life symptoms.       Presentation PDF      Presentation and video

Cost Benefit of Elastomeric Infusors in a Residential Palliative Care Setting – This initiative examined the cost associated with using elastomeric infusors (not CADD pumps) and compared it to the cost of regularly administered medications by conventional methods. Aspects considered include nursing time, supply usage, and medication wattages.  Presentation PDF

Using Electronic Clinical Management Systems to Drive Best Practices in Palliative Care – Electronic order sets that guide correct formulation and dispensing guidelines and supports physicians with decision making when transitioning from oral to infusion-based medications.Electronic order sets that guide correct formulation and dispensing guidelines and supports physicians with decision making when transitioning from oral to infusion-based medications.  Presentation PDF     Watch video

COMMUNICATION

Whole Community Palliative Rounding: An Innovative, Collaborative Approach for Rural BC – Population-based “Whole-Community Palliative Rounds” is used in rural communities to facilitate a process for inter-professional sharing of collective clinical expertise and knowledge to address the immediate palliative care needs of persons and families. Presentation PDF    Watch video

Reducing the Silo Mentality – This innovation builds collaboration between established health care programs who traditionally work in silos, to provide seamless palliative care to a population of frail seniors that have not previously been able to access palliative care services. Presentation PDF      Watch video

Integrated Palliative Care Approach in Home Care – An interdisciplinary, interdepartmental team model comprised of the client and their family/caregiver(s), palliative trained nurses and personal support workers (PSWs) that is strategically designed to encourage and promote communication. Presentation PDF    Presentation and video

Spectrum Health Care’s Operational Excellence in MAiD – Build on three core perspectives – patient/caregiver, provider and system; this MAID (medical assistance in dying) program uses clear protocols, procures and rigorous training to support community nurses and team-based care. Presentation PDF

The Integration of Palliative Home Care Services and Acute Care Teams in the Provision of Medical Assistance in Dying in the Community – In 2016, the Champlain LHIN Palliative Home Care Program joined forces with The Ottawa Hospital (TOH) in order to provide MAiD to palliative patients in the community. Palliative home care services now support acute care physicians in offering MAiD in the community, resulting in care that is more patient-centered and with improved communication.  Presentation PDF

The INSPIRED COPD Outreach Program™: Role of the Advance Care Planning Facilitator – As part of the INSPIRED COPD Outreach Program a trained advance care planning facilitator provides in home psychosocial/spiritual support, assisting patients/families in completing personal directives if desired. Presentation PDF     Presentation and video

Redefining the Circle of Care – A quality improvement initiative that sought to refine and expand the circle of care so as to better meet the palliative needs of people. Presentation PDF    Watch video

Provincial Palliative Care Consultation Phone Line – The toll-free Provincial Palliative Care Consultation Phone Line is a partnership between Doctors of BC and the Vancouver Community Home Hospice Palliative Care physicians. Presentation PDF    Watch video

The New Normal: The Palliative Clinical Resource Nurse Role in Community Home Health – An approach to embedding palliative clinical resource nurses (PCRN) into  home health sites and providing a vital link between acute care, residential care, hospice and community care. Presentation PDF      Watch video

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