Collaborating with Your Local Team

(35 minutes)

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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

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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

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Spectrum of collaboration

Parallel practice Consultation/referral Co-provision of care

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Transitions in life-limiting illness

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Time of

Diagnosis

Disease advancement

Complication indicators

Decompensation

experiencing life limiting illness

PPS

ESAS

BC Palliative benefits

Decline and last days

Dependency and symptoms increase

Home care

Death and bereavement

Transition 1

Time

McGregor and Porterfield 2009

Transition 5Transition 4Transition 3Transition 2

Early

Chronic Disease

Management

Hope for cure survivor

Seniors at risk

Transitions in life-limiting illness

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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

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Working together GP and Home and Community Care?

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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.

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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

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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.

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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.

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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

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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)  

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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.

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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.

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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

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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

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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)

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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.

2020

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 fingertipsHealth authority & other publicly-funded servicesPrivate, fee-based services All specialist physiciansA variety of allied health professionals

Improve your referral efficiency and effectivenessCut down on the time & frustration finding the right resource for patientsAccess relevant, detailed and organized information to ensure appropriate and complete referrals to the right provider

Built by and for physiciansAn initiative of the General Practice Services Committee (GPSC), operated by HealthLink BC, with input from physicians & MOAs

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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?

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Collaborative practice: Table discussion

Identify one aspect of care that you will do differently in your practice and when

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