Work Plan - Hospice Residence
Hospice Residences Regional ProjectBuilding capacity and enhancing care in Hospice Residences in Southeastern Ontario
Executive Sponsor: Allen Prowse, Board Chair, Hospice Kingston
Team Lead: Maggie George, Health Care Consultant
QI Advisor: Ruth Dimopoulos
Scoping the project
The scope of the project emerged from our diagnostic work which included use of quality improvement tools such as a fishbone (cause & effect) diagram and 5 why’s as well as process mapping of the referral and admission process to Hospice Residences (HRs). Caregiver surveys were undertaken with 14 caregivers and telephone interviews with 17 health care professionals to inform the project.
In addition to collecting information regarding the current operation of HRs, our project included a comparison of current HRs with the 2018 HR Standards from Hospice Palliative Care Ontario (HPCO), the Ministry of Health and Long Term Care's Hospice Capital Program Design Standards and Best Practices for Infection and Control Programs in Ontario (Public Health Ontario). Our work was to include the development of a planning guide for the SE LHIN to use in planning future HR bed allocations in the region.
Initial Findings:
• Occupancy rate at Heart of Hastings Hospice (HHH) and Hospice Prince Edward (HPE) is well below the MOHLTC target (80%) as is the average length of stay (ALOS) below the provincial average of 15 – 20 days.
• Some patients were being referred to HRs within a few days of their death.
• Identified need for greater public awareness of HRs for patients and families and of the referral and admission process for health care providers.
• Meeting Hospice Palliative Care Ontario (HPCO) standards related to RN response time and provision of 24/7 professional staff presents challenges beyond the control of the Hospice Residences. A large rural geography along with a lack of Personal Support Workers (PSWs) and Nurses (RNs & RPNs) in the region, contribute to these challenges. New models are being explored by the Hospice Residences.
• It is difficult to comply with the definition of an interdisciplinary team as described by HPCO as the care providers consist of three distinct groups: Home & Community Care, the Health Care Provider Agency and the Hospice Residence.
• The out of pocket cost incurred for transportation by families and patients to transfer patients to HR is high, especially on holidays and required up front. Timeliness was also an issue.
• The palliative care competency of nurses and personal support workers is variable.
Our Aim
By March 31, 2019, patients and caregivers choosing HR can expect improved access to quality HR services through standardized and coordinated processes and care delivery based on HPCO HR standards as measured by a 10% increase in occupancy rate at Heart of Hastings Hospice and Hospice Prince Edward and maintenance of high caregiver satisfaction with timely access to hospice.
Change Ideas
• PDSA with a focus on increasing the Palliative Performance Scale (PPS) admission threshold to 40% from 30% for cancer patients and on a case by case basis for other diagnoses in order to increase occupancy rate to comply with MOHLTC directives (80%) and increase ALOS to an average of 18 days.
• Monitor time between referrals and admissions to determine if weekend admissions are required.
• Raise awareness of HRs by developing materials for the general public and health care professionals regarding HRs.
Accomplishments/Results
• A checklist for data capture was developed for the PDSA.
• Occupancy rate increased to meet the MOHLTC target.
• ALOS was variable but increased for admissions at PPS 40%. Waitlist criteria were developed (HR's and HCC)
• In the majority of cases (70%) admission to hospice after referral was the same or next day.
• Out of the patients post PDSA initiation (n=27), two patients waited over the week-end for a bed. Admission over the week-end does not appear to be needed at this time.
• HPCO standards, MOHLTC Capital Program Design Standards and Best Practices for Infection Prevention and Control were reviewed with HHH and HPE. There was high compliance with all standards and recommendations were made for initiatives to meet any unmet standards. Steps have already been taken to address any outstanding issues; for example, 24/7 professional care is now available at both HRs.
• Shared learning between hospices was beneficial when reviewing the standards.
• A caregiver satisfaction survey was developed and implemented. Survey Monkey was set up to collate results. Results indicate that caregivers are very satisfied with the care their family member/friend received and caregivers felt that they were also well supported.
• Materials for patients, caregivers and health care professionals were developed in a couple of formats to increase awareness of HRs and what they provide.
• Transportation to HRs is now provided by one provider. Quality has improved with better service delivery and communication.
To view the Project Master Slide Deck click here
Coach Note: There are signals of change (improvement) in the occupancy run charts for both hospices. Click here for more information about interpreting run charts.
Moving Forward
• Plans are in place for HRs to continue to collect the checklist data and caregiver satisfaction survey data
• The HR team recommends that referrals to HRs continue to be made at PPS 40% and in conjunction with the Gold Standards and illness trajectories that patients be admitted to HRs when appropriate
• Ongoing education be provided to RNs, RPNs and PSWs involved in HRs. Individuals providing patient assessments have a refresher course in PPS, Gold Standards, etc.
• Raising awareness materials should be reviewed and tested when clarity regarding MOHLTC structures and processes are forthcoming.
• The SE document to provide guidance in planning for future HR bed allocations in the region should be continued again when MOHLTC structures and processes are finalized.
• HRs will strive to meet all HPCO standards within their new funding model.
Project Limitations and Duration
Proposed changes to the health care system made by the MOHLTC resulted in postponing initiatives that included LHIN structures and processes. Within SE Ontario, HRs need to focus on a new funding model and how they will operate within the new environment.