Palliative And End Of Life Care (PEOLC)
PALLIATIVE AND END OF LIFE CARE(PEOLC)Adult and Pediatric Clinical DocumentationCurrent State, Dependencies & Desired StandardizationPalliative and End of Life Care (PEOLC)Clinical Documentation Working GroupRevised December 17, 2018
IntroductionIn preparation for the provincial Clinical Information System (CIS) the PEOLC Clinical DocumentationWorking Group has initiated the identification and standardization of future state documentation requirements.This report outlines work completed on defining current state documentation, identifying dependencies andrecommendations or desire to standardize.The Connect Care Clinical Documentation Working Group Terms of Reference (Appendix A) provide amore detailed description of the deliverables and include Working Group membership.The palliative and end of life care health information and tools available within the MyHealth.Alberta.cawebsite and The Alberta Health Services Palliative and End of Life Care Alberta Provincial Framework 2014provided the foundation to the work outlined in this report.The following Connect Care Guiding Principles and the Clinical Documentation Framework 2017provided additional guidance:1. Put patients and families first.Enhance safety and improve the healthcare experience.2. Move fast.Make timely, clear and actionable decisions, staying on schedule.3. Integrate across the continuum.Favour seamless information flows over niche solutions.4. Avoid unhelpful variation.Adopt evidence-informed, provincially standardized, guidance and workflows.5. Adopt and adapt.Express AHS best practice, leveraging Epic content to fill gaps.6. Use tools for transformation.Do not entrench old inefficiencies with new technologies.7. Lead with purpose.Maximize engagement of clinical and operational leaders.8. Partner to advantage.Fully leverage Epic’s experience, offerings and relationships.9. Transform With Intent.Monitor and measure expected benefits and unexpected harms.10. Heed best experience.Collaborate to make the most of Epic’s Good Install program.1
AcknowledgementsThe Palliative and End of Life Care Clinical Documentation Working Group has contributed to thedevelopment of the information included in this report and includes the following members.NameTitleRoleZoneProject SponsorDr. James SilviusProvincial Medical Director, SeniorsHealth, Community, Seniors, Addictions &Mental Health Senior Medical Director,Seniors Health SCNSponsorProvincialTracy Lynn Wityk MartinLead, PEOLC, Community, Seniors,Addiction and Mental HealthCo-ChairProvincialAurora LeangProject Coordinator, PEOLC, Community,Seniors, Addiction and Mental HealthCo-ChairProvincialClinical Informatics Lead, ClinicalDocumentationWorking GroupMemberProvincialSyed Asif AjazClinical Informatics Analyst, ClinicalDocumentationWorking GroupMemberProvincialMichelle Peterson FraserSenior Consultant, PEOLC, Community,Seniors, Addiction and Mental HealthWorking Group MembersPenny KwasnyWorking GroupMemberProvincialContinuingCare ConnectCare AreaCouncilMemberSubject MatterExpertDr. Ayn SinnarajahMedical Director, Palliative/End of LifeCareWorking GroupMemberCalgary ZoneBev BergDirector, PEOLCWorking GroupMemberCalgary ZoneCarleen BrenneisDirector, Palliative InstituteWorking GroupMemberEdmontonZoneCatherine JanzenArea Manager, PEOLCWorking GroupMemberCalgary Zone2
NameTitleRoleZoneChandra VigCare Manager, Palliative Care ConsultServiceWorking GroupMemberCalgary ZoneCynthia JohnsonDirector Palliative/ End of Life Care andCommunity ProgramsWorking GroupMemberEdmontonZoneErin ForsythManager, Hospice Operations and HospiceAccessWorking GroupMemberCalgary ZoneGreg DuchschererProgram Director – ClinicalDocumentation, Clinical Knowledge &Content Management- CMIOWorking GroupMemberProvincialJanice HagelManager, Palliative Care Consult ServiceWorking GroupMemberCalgary ZoneKaren ButelArea Manager Pediatric Home CareProgram & Rotary Flames HouseWorking GroupMemberSouth SectorKatie MahonProgram Manager, CCS; PediatricsWorking GroupMemberNorth SectorLeAnn EsauManager Home Care Raymond, Magrath,Coaldale, Lethbridge SoutheastWorking GroupMemberSouth ZoneWestDr. Leonie HerxMedical Director, Intensive Palliative CareUnit, Calgary ZoneWorking GroupMemberCalgary ZoneLinda WatsonLead, Person-Centered Care Integration,Provincial Practices, Cancer Control (TBCC,Cross Cancer, Oncology Clinics)Working GroupMemberProvincialLouise VerklanSenior Consultant, Central Zone StrategicCoordination, Primary Health CareWorking GroupMemberDr. Marli RobertsonMedical Director, Children’s Hospice andPalliative Care Service and Rotary FlamesHouseWorking GroupMemberSouth SectorMary SabbePractice Lead, Central ZoneWorking GroupMemberCentral ZoneMax JajszczokExecutive Director, Seniors HealthCommunity, Seniors, Addiction and MentalHealthWorking GroupMemberProvincialNatalie HousemanPatient Care Manager, Pediatric Oncology,Hematology and Palliative CareWorking GroupMemberNorth SectorPam CummerRegistered Nurse, Central ZoneWorking GroupMemberCentral ZoneProvincial3
NameTitleRoleZonePansy AngevineZone Specialty Programs ManagerWorking GroupMemberCentral ZoneRhonda BolzPalliative Care Nurse ConsultantWorking GroupMemberSouth ZoneEastRhonda NiebruggeManager, Intensive Palliative Care Unitand Unit 36, Foothills Medical CentreWorking GroupMemberCalgary ZoneWorking GroupMemberEdmontonZoneDr. Robin FainsingerClinical Director, Tertiary PalliativeCare Unit, Grey Nuns CommunityHospital, Section Chief, PalliativeCare ProgramDr. Russell LoftusPalliative Care Consult PhysicianWorking GroupMemberCalgary ZoneSandra YoungAccreditation Advisor, AccreditationWorking GroupMemberProvincialTara WrenASSIST Coordinator Stollery Children'sHospitalWorking GroupMemberNorth SectorTerri WoytkiwManager, Specialty ProgramsWorking GroupMemberNorth ZoneDr. Lyle Galloway or Dr.Sharon WatanabePalliative Tumour TeamWorking GroupMemberProvincialHeather VintProvincial Director Program Management,Community, Seniors, Addiction and MentalHealthConsultant,Continuing CareConnect Care AreaCouncilProvincialKelly HalsethDirector, Forms Strategy & ManagementConsultantProvincialSandra GuginsSenior Consultant - Clinical Informatics,Quality, Information Management,Projects and Evaluation - Community,Seniors, Mental Health and AddictionsConsultantProvincialAd Hoc Members4
PEOLC Clinical Documentation RepresentationPEOLC Current state clinical documentation requirements have been identified in the following clinicalstreams: Intensive Palliative Care Unit/Tertiary Palliative Care Unit Hospice/PEOLC community supported beds in Supported Living Integrated Home Care/Palliative Home Care Outpatient Clinic Consult Team (various care settings) Acute Care, including but not limited to Inpatient Cancer Care and designated PEOLC bedsWithin each of the following areas: Referral to service Screening for service Admission assessment Initial consult/visit Daily/every consult Discharge/death Referral from service As needed5
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AdultsAdult Provincial StandardizationExisting:1. Palliative Performance Scale (PPS)2. Advanced Care Planning/Goals of Care Designation Policy, procedure, tools and resourceswww.conversationsmatter.ca3. Palliative and End of Life Policy (for continuing care and is a Continuing Care Health ServiceStandard)4. Clinical Knowledge Topic: Advanced Care Planning/Goals of Care Designation (ACP/GCD)Note: Covenant Health has their own similar policies for #2 and 3.In progress:1. Guideline: Patient’s Death in the Home Setting HCS-213-01(provincial implementation to becompleted by April 30, 2018); includes Expected Death in the Home form and instructions re:documentation2. Clinical Knowledge Topic: Care of the Imminently Dying3. Clinical Knowledge Topic: Palliative SedationNote: Covenant Health is updating a policy for Care of the Imminently Dying.Adult Primary PEOLC ToolsPrimary PEOLC tools refers to those tools specific to the clinical area.Used by most PEOLC streams:1. Palliative Performance Scale (PPS)2. Edmonton Symptom Assessment Scale-Revised (ESAS-R)Used by one or more PEOLC streams:1.2.3.4.5.6.7.Agape Hospice Family SurveyBereavement Risk Assessment Tool (Victoria Hospice Society 2008)Complexity Tool (Grief Assessment)Eastern Cooperative Oncology Group Performance Status (ECOG)Edmonton Classification System for Cancer Pain (ECS-CP)Palliative Prognostic Index (PPI)Palliative Outcome Scale (POS)-modifiedHome Care Specific Primary Tools (Used in all zones):1. End of Life (EOL) Comprehensive7
Home Care Specific Primary Tools (Used in 4/5 zones; Meditech electronic health record):1.2.3.4.5.Palliative General Physical AssessmentDeath at Home: ExpectedEnd of Life PrearrangementPalliative Care IntakePalliative Psychosocial AssessmentThere is nothing palliative specific built into PARIS. Calgary home care does use an end of lifecomprehensive assessment but it is not built in PARIS.Adult Secondary PEOLC ToolsSecondary tools refers to those tools used, but not lead by the clinical area.A complete list of the secondary tools can be found in Appendix B.Categories of Secondary tools used by some PEOLC 8.19.20.21.22.23.24.25.26.27.28.29.Alcohol UseAnticholinergic BurdenAnxiety/DepressionBowel FunctionConfusion FrailtyFunctionGrief and BereavementMedication relatedMental StatusMotorNephrologyOutcomesOral HealthPainProblem ChecklistPrognosticRespiratorySedation ScaleSpiritual CareSatisfaction SurveySocial WorkTissue DonationTuberculosisWound/Skin Assessment8
Adult PEOLC DependenciesThe current primary PEOLC tools and the secondary tools used within the PEOLC streams supportpalliative and end of life care standards and reporting requirements.1.2.3.4.5.6.7.8.9.10.11.12.13.Care planningZone specific reporting (PPS/ESAS-R/POS-modified)Provincial prioritized indicators and parametersContinuing Care Health Service Standards (CCHSS)Alberta Continuing Care Information System (ACCIS)AccreditationCanadian Institute for Health Information (CIHI)Resident Assessment Instrument (RAI-HC and RAI-LTC 2.0)Other information systemsa. Netcareb. Strata PathWaysc. Pixalere Wound Management SystemAlberta Health (TBD)Information Flow (may be out of scope for the working group)a. Examples include integration with vendors and the Palliative websiteAdvance Care Planning Collaborative Research and Innovation Opportunities Program (ACPCRIO)a. Nine Advance Care Planning/ Goals of Care Designation indicators were created by CRIOand have been integrated into the provincial AHS evaluation of ACP/GCD.Emergency Medical Services (EMS) PEOLC Assess, Treat, Refer program phase 1, 2 and this fiscalyear phase 3. An evaluation logic model is attached to this program with specific data elementsbeing captured for outcome measurement.Adult Desired StandardizationRecommendations/Decisions by Working Group (WG):1. January 29, 2018 PEOLC Clinical Documentation WG MeetingThe PEOLC Clinical Documentation Working Group requests the Victoria Hospice PalliativePerformance Scale (PPS) as a provincial documentation standard inclusive of ambulation, abilityto do activities, self-care, intake and level of consciousness.2. February 12, 2018 PEOLC Clinical Documentation WG MeetingThe PEOLC Clinical Documentation Working Group requests both the Edmonton SymptomAssessment System Revised (ESAS-R) and Palliative Outcome Scale (POS) modified as provincialdocumentation standards.3. April 2, 2018 PEOLC Clinical Documentation Working Group MeetingThe Working Group requests PEOLC specific comprehensive and intake assessments that can beflexibly applied across care settings. These assessments do not yet exist (across care settings)and would need to be built, possibly leveraging existing assessments in certain PEOLC streams.9
PediatricsPediatric Provincial StandardizationExisting:1. Advanced Care Planning/Goals of Care Designation (ACP/GCD) Policy, procedure, tools andresources2. Clinical Knowledge Topic: Advanced Care Planning/Goals of Care DesignationIn progress:1. Guideline: Patient’s Death in the Home Setting HCS-213-01(provincial implementation to becompleted by April 30, 2018); includes Expected Death in the Home form and instructions re:documentation2. Organ Donation after Death (Calgary Acute Care sites)To be developed in 2018-2019:1. Clinical Knowledge Topic: Pediatric Care of the Imminently Dying2. Clinical Knowledge Topic: Pediatric Palliative SedationPediatric Primary PEOLC ToolsPrimary PEOLC tools refers to those tools specific to the clinical area.1. Pediatric Client Comprehensive (Meditech)o This is being done across the province but there is not one standard form in use2. Palliative General Physical Assessment (Meditech)3. End of Life Prearrangements (Meditech)These three tools are from Meditech and are used by home care in Meditech zones.PARIS (Calgary home care system) includes similar assessments to those built in Meditech but may havedifferent information.Pediatric Secondary PEOLC ToolsSecondary tools refers to those tools used, but not lead by the clinical area.A complete list of the secondary tools can be found in Appendix C.Categories of Secondary tools used by some Pediatric PEOLC streamsNote: A complete listing of the tools included in each category is attached.1. Development10
2.3.4.5.6.7.8.9.Early LearningFallsMotorPainPerformance MeasurementQuality of LifeSedation ScaleWound/Skin AssessmentPediatric PEOLC DependenciesIncludes the reporting and analytics requirements related to clinical documentation.1. Care planninga. Nothing formal in place2. Zone specific reportinga. Currently, pediatric PEOLC utilization data is being collected at the zone or local level3. Advance Care Planning Collaborative Research and Innovation Opportunities Program (ACPCRIO)a. Nine Advance Care Planning/ Goals of Care Designation indicatorsi. Indicators relevant to pediatrics have been aligned. These are not beingreported at a provincial level.4. Emergency Medical Services (EMS) PEOLC Assess, Treat, Refer for pediatrics is in the process ofbeing developed this fiscal year (2018-2019).5. Alberta Health (TBD)Desired StandardizationRecommendations by Pediatric Sub-Working Group (WG):1. April 9, 2018 Pediatric PEOLC Clinical Documentation Sub-Working Group Meetinga. Interest in standardizing pediatric PEOLC comprehensive assessment and care plansacross the continuum of carei. May require more than one assessment to meet the requirements of thedifferent PEOLC streamsb. An AHS protocol on discontinuing life sustaining care would be helpfulc. Interest in exploring opportunity to standardize templates for provincial pediatric PEOLCconsult servicesNext StepsThis report will be shared with the Continuing Care Are Council. The PEOLC Working Group will continueto meet to identify, prioritize and standardize future state documentation requirements and will addressother needs that arise from working group discussion or as directed by the Continuing Care AreaCouncil.11
Appendix APurposeUnder the direction of the Connect Care Clinical Documentation Committee, the Clinical DocumentationWorking Group will develop provincially agree upon standardized clinical documentation best practiceclinical content guidelines in preparation for the provincial Clinical Information System (CIS). Consistentdocumentation practices benefit everyone. Communication, access to information and care planningimprove when practitioners speak the same language the same way. Effective clinical documentationincludes patient assessments, statements of goals, care plans and transition tracking; all supportingintegrated teams working across the continuum of care.The Clinical Knowledge & Content Management (CKCM) team coordinates and facilitates the activities ofprogram-specific and discipline-specific clinical documentation working groups comprised of physicians,nursing and allied health. This promotes adoption of best practices, builds consensus aboutdocumentation norms, exposes clinically essential documentation components, and reduces unhelpfulprogram-to-program variation.Clinically relevant documentation will best be achieved by identifying all data elements that are necessaryfor a clinician to consider in their practice, including information that is important but not necessarilydocumented by them. Clinical documentation should be collaborative and consider all clinicians whomight document or view it.Validation by the working groups will be based on the collective knowledge and availability of informationand best evidence at the time. Ongoing review and validation will occur as new information becomesavailable.DeliverablesAs per the Clinical Documentation Framework, each clinical area or discipline is responsible for identifyingand standardizing future state documentation requirements for their clinical program area or discipline(section 3.3). The working group is accountable for the following tasks required to achieve deliverable:1. Define current state documentation requirements:a. Admittingb. Intake/Admission Assessmentc. Daily Assessmentd. Care Plane. Transition Planningf. End of Service2. Analyze and incorporate dependencies:a. Role based documentationb. Reporting requirementsc. Analyticsd. Performance Outcomes/Measure/KPIse. Accreditation requirements12
3.4.5.6.f. Best practice standards (local, national, international)g. AHS policy & procedureDefine future state requirements for clinical documentation:a. Admittingb. Intake/Admission Assessmentc. Daily Assessmentd. Care Plane. Transition Planningf. End of ServiceSupport design of the provincial clinical information system and paper formsSupport implementation and change management plansSupport plan for review and optimizationMembership ModelThe program-specific working group is comprised of clinical subject matter experts from each zoneincluding nursing, allied health, physicians.The discipline-specific working group is comprised of clinical subject matter experts from each zone,including representation across the continuum of care that the discipline works.In order to ensure continuity of decisions between working groups, working groups shall have crossrepresentation (i.e., social workers on the Social Work Clinical Documentation Working Group willrepresent social work on different Program Clinical Documentation Working Group; and, whereappropriate, a specific social work will be identified to work on a standing basis with that program).See appendix for membership list.ResponsibilitiesCKCM Admin Support1. Schedule meetings in outlook2. Book meeting rooms as indicated3. Manage logistics (including travel, lodging) as indicatedCKCM Clinical Informatics Lead1. Prepare and circulate agendas2. Prepare materials for meetings3. Co-facilitate with program area Co-Chairs4. Document and circulate action items and decisions.Working Group Co-Chair(s):1. Primary contact with working group members2. Co-facilitates with CKCM Clinical Informatics Lead3. Facilitates decision making and sign off of deliverables4. Primary liaison with operational leadership5. Assists in escalation of issues according to Resolution Process (see below)6. Communicate and advocate changes with operational leadershipThe Working Group members:1. Represent clinical program area or discipline, providing clinical and contextual expertise2. Make decisions on behalf of their zone/area/program/discipline3. Ensure decisions and actions of the work group give consideration to:a. Impact to patient safety, accreditation and qualityb. Identification of any challenges and barriersc. Identification of impact across the province4. Communicate about how the change directly impacts zone/area/program/peers by being the localvoice and acting as a conduit for both formal & informal communications13
5. Advocate the benefits of the change6. Identify, manage and address specific issues and concerns within theirzone/area/program/discipline7. Identify resource, geographic
The palliative and end of life care health information and tools available within the . MyHealth.Alberta.ca. website . and. The Alberta Health Services Palliative and End of Life Care Alberta Provincial Framework 2014 . provided the foundation to the work outlined in this report. The
DEPARTMENT DIVISION NAME Family Medicine Palliative Medicine Algu,Kavita Palliative Medicine Arvanitis,Jennifer Palliative Medicine Berman,Hershl (Hal) Palliative Medicine Buchman,Stephen (Sandy) Palliative Medicine Cellarius,Victor Palliative Medicine Goldman,Russell Palliative Medicine Hashemi,Narges Palliative Medicine Howe,Marnie
Section 3 - Developing Quality Palliative and End of Life Care 1. Open discussion about palliative and end of life care should be promoted and encouraged through media, education and awareness programmes aimed at the public and the health and social care sector. 2. The core principles of palliative and end of life care should be a generic
4.4 Key findings on the current state of palliative and end of life care provision 37 4.4.1 Unmet needs and disparities in access to palliative and end of life care 38 4.4.2 Unmet needs and disparities when in receipt of palliative and end of life care 39 4.5 Ways forward: Recommendations for policy, practice and research
Regional Palliative and End-of-Life Care Coordinator. Senior CommUnity Care, Western CO. thosmith@voa.org Tom is passionate about educating others on palliative and end-of-life care. He is the co-chair of the National PACE Association's Palliative and End -of-Life Workgroup As an employee of Volunteers of America, he works with
The Strategy Unit Palliative & End of Life Care in the West Midlands, 2017 i S:\Commissioning Intelligence And Strategy\Strategic Analytics\Projects 2016\NHSE WM EoLC\report\final update\Palliative and End of Life Care in the West Midlands - final - 171005.docx Document Title Palliative and End of Life Care in the West Midlands Job No SU331
The most current directives guiding both Palliative & End of Life Care is the Ambitions for Palliative & End of Life Care 'A national framework for local action 2015-2020' and the Five Year Forward View for the NHS published by Simon Stevens in 2015. 3.1 The 6 Ambitions for Palliative &End of Life Care
1 Palliative Care Quality End of Life Care Resource Book Palliative Care Needs Round Checklist (Based on the ACU and Calvary Palliative Care Needs Rounds Checklist) Palliative Care Needs Round Checklist Triggers to discuss resident at needs rounds One or more of: 1. You would not be surprised if the resident died in the next six months 2.
palliative care plan 2012-2016 Inpatient palliative care There are 300 specialist palliative care beds located in NSW public hospitals, affiliated hospitals and other facilities in the NSW health system. Care is also routinely provided in non-designated palliative care beds. In 2008-09, there were 19,800 palliative care
