Enhancing family physician capacity to deliver quality palliative home care

Enhanced and integrated teams

The EPCT included a full-time palliative care advanced practice nurse (APN), a part-time palliative medicine physician (PMP), a psychosocial-spiritual advisor, a bereavement counselor, and a full-time Community Care Access Centre (CCAC) case manager. Self-selected “Physician Practice Leaders” from each of the 3 family practice groups involved in the project were mentored by the EPCT in palliative care knowledge and skills and given support to attend training courses. The practice leaders, the APN, and the PMP all joined an on-call roster available to the community nurses and doctors 24 hours a day, 7 days a week, for advice during off hours. The APN was a “navigator” for communication between team members, clinical coordination of care, and overall patient care. The psychosocial-spiritual advisor provided counseling support, while the bereavement counselor provided bereavement risk assessment and support. The CCAC palliative care case manager was part of the team to ensure effective resource allocation consistent with care needs.

The APN, the bereavement counselor, and the psychosocial-spiritual advisor were funded by an Ontario Primary Health Care Transition Fund (PHCTF) grant (www.hc-sc.gc.ca/hcs-sss/prim/phctf-fassp/index_e.html). The CCAC covered the case manager’s salary, and the PMP continued in her previous fee-for-service model but received a stipend from the PHCTF for educational sessions with the participating family physicians. Stipends for the on-call roster were also supported by the PHCTF grant.

Access and assessment

Case finding and screening ensured that family physicians and patients received timely access to the EPCT. Using triage methods supported by health systems planners,17 the following screening questions were developed for the family physicians to consider:

1. Would you be surprised if this patient died in the next 12 months?

2. If no, does this patient have pain, symptom issues, or supportive care needs?

Family physicians and their staff were encouraged to refer patients who met these criteria to the shared-care team. The EPCT provided consultations and visits to the patients and families according to the needs expressed by the family doctors or community nurses. Care plans were made and implemented as a group. The EPCT involvement was flexible and was dictated by the needs of the patients, the families, and the family physicians. The family physicians remained the ones most responsible for their patients, with the EPCT involved as collaborators in care and second-line support. The family physicians could request any member of the EPCT for joint visits. A “case navigation” binder was created for each patient, for the patient to take home, and contained a list of contacts, clinical assessment schedules, and various assessment tools. The EPCT created and used an interprofessional documentation form (Figure 2) based on the “Square of Care”18 to assess patients’ needs and develop care plans that enabled all team members to contribute their expertise. Patient assessment tools included the Edmonton Symptom Assessment Scale,19 the Confusion Assessment Method,20 the Palliative Performance Scale,21 and the National Comprehensive Cancer Network’s patient and caregiver distress scale.22

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Figure 2

Palliative care interprofessional team documentation

Coordinated, continuous care

Communication between members of the EPCT and the family physicians was a priority. Referred patients were discussed at weekly EPCT meetings to ensure optimal documentation, communication, and coordination of care. The integration of family physicians as team members, using the APN as a link to family practice offices, and the communication mechanisms such as weekly updates to family physicians were critical elements of the model. The APN in particular was the key point of contact among the family physicians, patients, and families, and the other EPCT members across care settings. Strong foci for the APN included helping all providers with early symptom identification and leading clinical problem solving.

Education and decision support

The APN and the PMP identified educational needs of physicians and community nurses and coordinated practice-based, evidence-based strategies (“just in time” case-based teaching, chart reviews, academic detailing) to improve the knowledge, skills, and confidence required to deliver optimal care. Table 2 summarizes the topics covered during the 15 clinical and educational multidisciplinary sessions held in all 3 practices. These sessions were open to the physicians’ practice teams (nurses, pharmacists, students), the EPCT, and community nurses. The Physician Practice Leaders assumed leadership for these sessions as the project progressed.