Home-Based Palliative Care

Building Operational Excellence

Operational Innovations in Home-Based Palliative Care

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 Plans Assessment and Care Planning

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

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

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

Effective Communication Strategies and Tactics

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

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

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

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

Supplies, Equipment and Medication Management

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

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 wastages.
Presentation PDF

Inclusion of advance care plans into the delivery of care in the home

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.
Presentation PDF

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