As the burden of after hour on-call duty took its toll the number of physicians willing to undertake such work dwindled over time. The philanthropic environment has also become increasingly competitive with ever more causes vying for charitable donations. With decreasing physician availability and no financial relief in sight, Yee Hong made the difficult decision to wind down the in-home palliative care service by March 2008. In its place, Yee Hong is hoping to establish a residential hospice. Meanwhile, local residents with palliative care needs are short on access to clinical support to remain home.

Recognizing the loss of a specialized resource, the Central East Local Health Integration Network (CE-LHIN) encouraged Yee Hong to explore with other hospice palliative care providers means by which to bridge this service gap.

Rethinking Delivery of Community Palliative Care Services

A Partnership Approach to Planning

In November 2007, Yee Hong convened a planning partnership with:

• The Central East Community Care Access Centre (CE-CCAC);
• The Rouge Valley Health System – Oncology Service;
• The Dorothy Ley Hospice – Palliative Pain and Symptom Management Consultation Service for Toronto;
• The Scarborough Hospital – Cancer Care Service;
• The Victorian Order of Nurses (VON) – Scarborough Hospice;
• A community pharmacist from Scarborough; and,
• A Scarborough based palliative care physician.

Also providing advice was the CE-LHIN Aging at Home Strategy Consultant.

The Challenge

1. Physician availability is critical to meeting palliative pain and symptom management needs if those nearing end-of-life are to remain at home.
2. Other hospice palliative care services in Scarborough are already in heavy demand.
3. Enabling nurses to pronounce death in community abodes when necessary will significantly lessen the burden on physicians managing palliative patients. Special dispensation by the Coroner’s Office to allow for non-physicians to pronounce death will need to be secured.
4. Delivery of a community based palliative care service involving multiple Health Services Provider (HSP) partners has few precedents. Establishing joint management structure and operational processes will require determined efforts by all partners.

This planning partnership therefore resolved:

1. To bridge the service gap between closure of the incumbent in-home palliative care service and realization of the Yee Hong Residential Hospice.
2. To better utilize scarce physician resources, and address their need for support.
3. To support a multi-disciplinary approach to meeting the full range of end-of-life needs of individuals and families.
4. To leverage palliative care resources already available in the Scarborough area.
5. To formulate a service heretofore to be identified as the Yee Hong (Scarborough) Community Palliative Care Service (a.k.a. the Service to address these challenges.

Target Clientele

Terminally ill individuals with “complex” palliative pain and symptom management requirements are best cared for in hospitals. Others nearing end-of-life seek to live out their days at home might also experience similar pain and symptom but not enough to warrant hospitalization. It is this latter group the Service seeks to provide care for. The availability of clinicians to intervene where they live will help them stay out of hospitals.

Service Features

The Service has five key features:

1. For each palliative patient there is a Most Responsible Physician (MRP) supervising and directing his care. Ideally, this will be one’s family physician or a palliative care physician who assumes care responsibility. If neither is available the Service will assist with finding a MRP. Along with multidisciplinary resources that can be mobilized through the CE-CCAC Palliative Care Program, the Service will support the MRP with services delivered by a Nurse Practitioner (APN).
2. Having access to sufficient medical support is the biggest challenge to a home dwelling individual with palliative pain and symptoms. To care for him an MRP will have to make an amount of home visits. However, the MRP will also have the option of issuing standing orders for qualified clinicians to implement such palliative care therapy as necessary. The Service will be staffed with APN’s who will visit and respond to calls by patients, families, and community nurses seeking consultative advice and directions to cope with evolving palliative pain and other symptoms. They will consult with the MRP’s as necessary to formulate, adjust, and implement treatment plans, act on their extended scope of practice to provide advice to patients and medical directions to other clinicians who would otherwise have to look to the MRP’s for instructions and medical orders.
3. While pain and symptom management is anchored by medical and nursing intervention, palliative care also requires the expertise of pharmacists, physical therapists, social workers, and chaplains etc. The Service will facilitate linkages with such services to assist their patients/clients and families.
4. Care needs change over time and for innumerable reasons. While most of the target clientele are not expected to require hospitalization, some will. The Service will facilitate expedited hospital admission when necessary.
5. The Service will partner with the CE-CCAC and the Palliative Pain and Symptom Management Consultation Service to provide training for the home hospice palliative care community. Doing so will both help build local service capacity, and encourage more physicians to become MRP(s) for palliative patients.

Figure (1) shows the proposed Community Palliative Care Service within the context of the local hospice palliative care sector.

Functional Processes

In keeping with the principle of “No Wrong Door to Access Services”, clients can activate the Service in one of two ways. Upon having been diagnosed with a terminal illness and resolved not to pursue curative treatment he or his physician can either:

1. Approach the Service directly, or
2. Contact the CE-CCAC to request palliative care services.

Where the first contact is with the CCAC, the client will go through intake and be connected to appropriate clinical services via the CCAC Palliative Care Case Manager and be referred to the Service.

If the client chooses to approach the Service first, while enrolling with the Service, he will also be automatically registered with the CCAC palliative care program thereby establishing eligibility to access associated multidisciplinary services when needed.

In both situations, the Service will quickly identify and establish contact with the MRP and put in place a shared care arrangement. With each client also registered with the CE-CCAC, a Case Manager from the latter can coordinate for comprehensive end-of-life care services to be provided to the individual and family as necessary.

By defining its function as including liaison with hospital palliative services the Service can also facilitate admission for clients who might need hospital care if their medical conditions become untenable for management in the community.

The New Community Palliative Care Service in Context

The Service is positioned as an integral component of the hospice palliative care service continuum in the Scarborough area. It is both an upstream and downstream partner to other HSP’s as client flow is not expected to be unidirectional. Client needs will determine when and from where service is accessed. Such needs will also determine when a client has to be handed off to other hospice palliative services.

Programmatically, Service success is dependent upon collaboration across the local hospice palliative care sector. An oversight committee will provide guidance and advice as the Service evolves through the two years of pilot operation. Yee Hong, as host agency, will monitor and report to the CE-LHIN through a service accountability agreement.

Implementation and Beyond

This Community Palliative Care Service has been included by the CE-LHIN in their Detailed Service Plan 2008 – 2009 submitted to the Ministry of Health and Long-Term Care in the context of the Aging at Home Strategy. Once Ministry approval is secured, staff recruitment and service implementation are expected to proceed expeditiously. It is intended that service delivery will commence by fall 2008 with 1.5 FTE Nurse Practitioners and a part-time Service Coordinator. Staffing complement will be ramped up to 2.5 FTE Nurse Practitioners for 2009 – 2010. The success of this pilot project will inform future hospice palliative care planning across the entire CE-LHIN region.