An Evolving System

• New technology and best practice• Changing community demographics,

population needs• Need for collaboration• Right care, right place, right time, right

provider

Hospice/Palliative Care – a growing issue?

• Need to support patients through their journey

• Raison d’être for North East Hospice Palliative Care Network, a network made up of home, hospital, and hospice providers and stakeholders

• Goal is to work with the North East LHIN to improve palliative care across the northeast

Patient Transitions – Palliative/End of Life

New Model

Smoothing the Journey

Community

• A number of palliative services providers in the community:– Care providers (primary)– CCAC– Community Support Services and volunteer providers– Hospital outpatient and outreach/inpatient – Long-Term Care Homes– Residential Hospice and outreach

North East CCAC – Professional Services

• Provide professional services:– Care Coordination– Therapies (Occupational and physiotherapy,

dietician, speech-language pathologist, social worker) - internal and contracted providers

– Nursing (clinic, in-home, shift), primarily contracted services through service providers

North East CCAC – Support Services

• Provide support services:– Personal support – contracted service– Short-term medical equipment rental– Medical supply provision

North East CCAC – Enhancing End of Life Care

• Internal initiatives to enhance chronic disease management and end of life care

• Enhanced and new services• Specialized knowledge and expertise

North East CCAC –Enhanced End of Life Services

Enhanced personal care, nursing and therapy services to support patients with end of life care needs (last 90 days of life)

North East CCAC Chronic Disease/Palliative Care Initiatives• Rapid Response and Telehomecare Nursing• Palliative Nurse Practitioner Program• Specialized Palliative Care Coordination Team• Enhanced palliative training for staff (multidisciplinary

palliative team pilot) • Integrated service planning pathways and guidelines • Provision of therapy services, medical equipment/supplies for

patients at Maison Vale Hospice

Warm Hearts

• Interdisciplinary education, volunteer visiting and the Bereavement Follow-up Program since 1989

• Accredited organization, screening process and intensive training for volunteers

Warm Hearts

• Sponsor agency for the Interdisciplinary Education Program

• www.warmhearts.ca or call 705-677-0077• Recent/ongoing integration with Maison Vale

Hospice

Maison Vale Hospice Community Outreach Services

• Shared Care Team for patients with complex needs – Specialized nursing– Supportive care– Physician/RN on-call, 24/7 – Consultation and resource

• Advanced Care Planning Strategy

HSN Palliative Services – Supportive Care

• Specialized individual and family counselling• Palliative and end of life care for First Nations, Inuit, and Métis

patients and families• Assistance with practical and financial matters• Specialized nutrition counselling • Physiotherapy for symptom management• Grief counselling for caregivers and families

HSN Palliative Services – Symptom Management Clinic

• Control of pain and other symptoms of cancer• Emotional, social and spiritual care • Educate for informed decision-making• Grief counselling for caregivers and families

Maison Vale Hospice - Residential Care

• Maison Vale Hospice provides residential hospice palliative care in a homelike environment

• Psycho-Social/Spiritual Care Program• Visiting Hospice Volunteer Program

Maison Vale Hospice – Admission Criteria

• Placement provided by the NE CCAC - 310-CCAC• Patient criteria:

– Over the age of 16– “End stage” medical condition, with a life expectancy of three

(3) months or less– Priority given to patients who live alone and cannot manage at

home alone, or hospital in-patient unable to return home wishing for EOL care with the Hospice

– Has symptoms that can be managed by residential hospice staff

HSN Inpatient Palliative Care

• Focus on pain and symptom management that cannot be provided in a community setting

• HSN Palliative Care Unit at HSN – 6 beds– Open to any palliative hospital patient whose EOL care

period is less than 4 weeks, or community patient with care period of less than 3 weeks

Conclusion

• Providers working together to enhance care and resources to improve information, options and outcomes for patients and families.

• For information please contact: – www.northeasthealthline.ca or,– 310-CCAC Information and Referral