Transitional Stage Palliative Care Pathway

Transcription

Transitional Stage – Palliative Care
POC LIGHT VERSION
Client Details
Name
Client ID
Date Pathway Activated
Date Pathway
Discontinued
Pathway Identification
Pathway Name
Presenting Issue or
Condition Defined
Exclusion Criteria
Coding Requirements
(e.g. specific local referral
codes)
Overall Pathway
Outcome
Pathway Evaluation
Date Created
Date Reviewed
(Subject Matter Experts)
Subject Matter Experts
Date Approved
Frequency of Review
Next Review Date
What triggers a special
condition review of
pathway
Version
Reason for
Stoppage
Drop-Down or radio button
o Moved to a different pathway
o List reason: ____________
o New pathway: ___________
o Admitted to Hospital
o Admitted to PCU
o Admitted to Hospice
o No longer palliative
o Deceased
o Other ______________________
Based on client’s functional performance as defined by the Palliative
Performance Scale (PPS). Transitional stage for palliative clients is defined
as clients with a PPS of 60-40 and or by the clinicians’ assessment upon
review of additional clinical indicators and or tools.
Clients <18 years-old
N/A
Elements in place to support the client and caregivers throughout the
palliative care journey.
May 28, 2012
TBD
TBD
[Created from 0v12 – October 29, 2012]
POC LIGHT VERSION 0v02-20121101
© Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access
Centres/Association des Centres d’accès aux soins communautaires de l’Ontario, 2012. All rights reserved. Unauthorized
distribution and duplication strictly prohibited.
Page 1 of 17
POC LIGHT VERSION
Interval
0 – 7 Days
Best Practice Guideline
Cancer Care Ontario:
Palliative Care
Collaborative Care Plan
– Transitional Stage
Outcome
o
Comprehensive,
holistic interprofessional clinical
assessment or
reassessment
completed
Reporting
o
SPO report
Outcome
Evaluation
o
Outcome not
met
Palliative Care
o
o
Canadian Hospice
Palliative Care
Association: A Model to
Guide Hospice Palliative
Care
0 – 7 Days
Barriers to Outcome
Achievement
o
o
Date: __________
o Clinical care plan
which incorporates
client values and
goals initiated/
updated
Date: ________
o SPO report
Date: __________
o Outcome not
met
Resource barriers
o Client/family
o SPO
o CCAC
o System
Client readiness
o Psychological
o Physiological
Client declined
Other
____________
Date:______________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Follow-up Actions
o
o
o
System
navigation to
address resource
barriers
Contact client /
caregiver
Other
______________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
© Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 2 of 17
POC LIGHT VERSION
0 – 7 Days
0 – 7 Days
Date: __________
o Plan for 24/7 access
and responsiveness
initiated/updated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date: __________
o Risk assessment or
reassessment
completed and
support in place to
ensure only
appropriate
hospitalization or ED
visits
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:______________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Premature
discharge from
hospital
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Page 3 of 17
POC LIGHT VERSION
0 – 7 Days
Edmonton Symptom
Assessment System –
Description
Date: _______
o ESAS administered
as indicated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date: __________
o PPS administered at
each visit
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Edmonton Symptom
Assessment System Tool
0 – 7 Days
Victoria Hospice
Palliative Performance
Scale - Description
Victoria Hospice
Scale - Tool
Page 4 of 17
POC LIGHT VERSION
0 – 14 Days
0 – 14 Days
21 – 28 Days
Date: __________
o CCAC client care
plan which
incorporates client
values and goals
initiated/updated
Date: __________
o CC
documentation
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date: __________
o Most responsible
physician and/or
support plan
identified/updated
Date: ________
o CC
documentation
Date: __________
o Outcome not
met
Date:______________
o Resource barriers
o Client/family
o CCAC
o Physician
availability
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address
resource barriers
o Advocacy
o Explore
alternative
supports
o Contact client /
caregiver
o Other
______________
Date:_____________
o Common access
Date: _________
o SPO report
Date:__________
o Outcome not
Date:_____________
o Resource barriers
Date:_____________
o System
Page 5 of 17
POC LIGHT VERSION
established/updated
to relevant client,
care and healthrelated information
met
o
o
o
21 – 28 Days
21 – 28 Days
Canadian Hospice
Palliative Care
Association: Speak Up –
Advance Care Planning
o Client/family
o SPO
o CCAC
o System
Client readiness
o Psychological
o Physiological
Client declined
Other
____________
o
o
navigation to
address resource
barriers
Contact client /
caregiver
Other
______________
Date: __________
o Advance Care
Planning
initiated/reviewed
with client and
documentation
updated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
o Plan for expected
death
initiated/updated
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
Date:_____________
o System
navigation to
address resource
Page 6 of 17
POC LIGHT VERSION
o
o
o
21 – 28 Days
21 – 28 Days
o CCAC
o System
Client readiness
o Psychological
o Physiological
Client declined
Other
____________
o
o
barriers
Contact client /
caregiver
Other
______________
Date:_____________
o Client preferred
place of death is
determined
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:___________
o Life completion
activities reviewed
with client and
documentation
updated
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
Page 7 of 17
POC LIGHT VERSION
o
o
21 – 28 Days
21 – 29 Days
o Psychological
o Physiological
Client declined
Other
____________
o
Other
______________
Date:___________
o Preparation for
bereavement aftercare needs initiated
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:___________
o Common access
established/updated
to relevant client,
care and healthrelated information
Date:___________
o CC
documentation
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Page 8 of 17
POC LIGHT VERSION
o
o
21 – 29 Days
21 – 29 Days
Client declined
Other
____________
Date: __________
o Funding resources
identified/updated
and referrals
complete
Date: __________
o CC
documentation
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date: __________
o Needs are being met
by community
supports/resources
Date: __________
o CC
documentation
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o Community
support or
resource
o Unavailable
o Waitlisted
o CCAC
o System
Client readiness
o Psychological
o Physiological
Date:_____________
o System
navigation to
address resource
barriers
o Advocacy
o Explore
alternative
supports
o Contact client /
caregiver
o Other
______________
Page 9 of 17
POC LIGHT VERSION
Client declined
Other____________
21 – 29 Days
Canadian Hospice
Palliative Care
Q28 Days
Palliative Care
Date:_____________
o Advance Care
Planning
initiated/reviewed
with client and
documentation
updated
Date:__________
o CC
documentation
Date:__________
o Outcome not
met
Date:_________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
o Clinical care plan
which incorporates
client values and
goals updated
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Page 10 of 17
POC LIGHT VERSION
Q28 Days
Q28 Days
Date: __________
o Plan for 24/7 access
and responsiveness
updated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date: __________
o Risk assessment
completed and
support in place to
ensure only
appropriate
hospitalization or ED
visits
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:______________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Premature
discharge from
hospital
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Page 11 of 17
POC LIGHT VERSION
Q28 Days
Edmonton Symptom
Assessment System –
Description
Date: _______
o ESAS administered
as indicated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date: __________
o PPS administered at
each visit
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date: __________
o Advance Care
Date: __________
o SPO report
Date: __________
o Outcome not
Date:_____________
o Resource barriers
Date:_____________
o System
Edmonton Symptom
Assessment System Tool
Q28 Days
Victoria Hospice
Scale - Description
Victoria Hospice
Scale - Tool
Q28 Days
Canadian Hospice
Page 12 of 17
POC LIGHT VERSION
Palliative Care
Planning reviewed
with client and
documentation
updated
met
o
o
o
Q28 Days
Q28 Days
o Client/family
o SPO
o CCAC
o System
Client readiness
o Psychological
o Physiological
Client declined
Other
____________
o
o
navigation to
address resource
barriers
Contact client /
caregiver
Other
______________
Date:_____________
o Plan for expected
death updated
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
o Client preferred
place of death is
updated
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
Date:_____________
o System
navigation to
address resource
barriers
Page 13 of 17
POC LIGHT VERSION
o
o
o
Q28 Days
Q28 Days
o System
Client readiness
o Psychological
o Physiological
Client declined
Other
____________
o
o
Contact client /
caregiver
Other
______________
Date:___________
o Life completion
activities reviewed
with client and
documentation
updated
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:___________
o Preparation for
bereavement aftercare needs updated
Date:___________
o SPO report
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
Page 14 of 17
POC LIGHT VERSION
o
o
Q28 Days
Q56 Days
Canadian Hospice
Palliative Care
o Psychological
o Physiological
Client declined
Other
____________
o
Other
______________
Date:___________
o Advance Care
Planning reviewed
with client and
documentation
updated
Date:___________
o CC
documentation
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
o CCAC client care
plan which
incorporates client
values and goals
updated
Date:___________
o CC
documentation
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Page 15 of 17
POC LIGHT VERSION
____________
Q56 Days
Q56 Days
Date: __________
o Most responsible
physician and/or
support plan
updated
Date: ________
o CC
documentation
Date: __________
o Outcome not
met
Date:______________
o Resource barriers
o Client/family
o CCAC
o Physician
availability
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address
resource barriers
o Advocacy
o Explore
alternative
supports
o Contact client /
caregiver
o Other
______________
Date:_____________
o Needs are being met
by community
supports/resources
Date: _________
o CC
documentation
Date:__________
o Outcome not
met
Date:_____________
o Resource barriers
o Client/family
o Community
support or
resource
o Unavailable
o Waitlisted
o CCAC
o System
o Client readiness
o Psychological
Date:_____________
o System
navigation to
address resource
barriers
o Advocacy
o Explore
alternative
supports
o Contact client /
caregiver
o Other
Page 16 of 17
POC LIGHT VERSION
o
o
Date:_____________
Date:__________
Date:__________
o Physiological
Client declined
Other
____________
Date:_________
______________
Date:_________
Page 17 of 17

Transitional Stage Palliative Care Pathway

Transcription

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