Work Plan - Better Communication

Better Communication within the Circle of Care Project (Rural Hastings Sub region)

Executive Sponsor:  Dr. Janet Webb, Family Physician, Central Hastings Family Health Team and Medical Director of Heart of Hastings Hospice in Madoc
Team Lead:  Alicia McCullam, Rural Hastings Health Link Project Manager
Current QI Advisors: Colin Wilson & Dana Summers



Since October 2017, working group members comprised of representation from Home and Community Care, Hospice, Primary Care, Hospital, Community, and a patient representative have been applying a quality improvement approach to the Regional Palliative Care Network priority project, “Better Communication within the Circle of Care”. The group has been tasked with identifying the root cause of the problem, collecting baseline data and working through improvement initiatives to identify and test changes of improvement for providers and patients at the end of life.
As a means to collect feedback from providers supporting patients at the end of life, a survey was created by the working group. The objective of the survey was to obtain feedback from health care providers on how they feel the information and communication flows when supporting their patients in the last 90 days of life. Thirty-six health care providers across the Rural Hastings sub-region completed the survey. In addition to the health care provider surveys, Experience Based Design Interviews were conducted with caregivers who have supported patients at the end of life as well as health care providers. A total of 20 interviews were conducted with caregivers and health care providers. 
Analysis of the Experience Based Design interviews and survey responses were conducted and the themes validated the root causes of the problem that were identified which include: informal relationships, too many providers involved, inconsistency in providers, no common tool for communication, and lack of awareness for who is on the care team. 
Our first approach to improvement is to embed a Home and Community Care Palliative Care Coordinator within one family health team one day a week to increase access to information and communication between the primary care team and Palliative Care Coordinator supporting patients in common. This will allow for improved relationship and ease of access to the information and delivery of services for patients. The embedded Palliative Care Coordinator will provide regular updates to primary care providers for patients in common and initiate case conferences with members of the care team when needed. They will also have access to the electronic medical record for documentation, providing updates and access to pertinent information.
Additionally, under the umbrella of the Rural Hastings Health Link EOL/Palliative Care working group, the team members created a discharge checklist for patients being discharged from hospital to home or hospice to support seamless transitions in care. The group has refined the checklist and is testing it at QHC.
The team members continue to collaborate on ideas that will improve communication for patients/caregivers and providers supporting individuals that require a palliative approach to care. 

Click here to view the Masterdeck for the Better Communication Project.

For more information about our project, please contact Alicia McCullam at 613-478-1211 ext. 248
Or amccullam@gatewaychc.org