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Seow H, Bainbridge D, Winemaker S, Stajduhar K, Pond G, Kortes-Miller K, Marshall D, Kilbertus F, Myers J, Steinberg L, Incardona N, Levine O, Pereira J. Increasing palliative care capacity in primary care: study protocol of a cluster randomized controlled trial of the CAPACITI training program. BMC Palliat Care 2023; 22:2. [PMID: 36604714 PMCID: PMC9813458 DOI: 10.1186/s12904-022-01124-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Primary care providers play a critical role in providing early palliative care to their patients. Despite the availability of clinical education on best practices in palliative care, primary care providers often lack practical guidance to help them operationalize this approach in practice. CAPACITI is a virtual training program aimed at providing practical tips, strategies, and action plans to provide an early palliative approach to care. The entire program consists of 12 sessions (1 h each), divided evenly across three modules: (1) Identify and Assess; (2) Enhance Communication Skills; (3) Coordinate for Ongoing Care. We report the protocol for our planned evaluation of CAPACITI on its effectiveness in helping primary care providers increase their identification of patients requiring a palliative approach to care and to strengthen other core competencies. METHODS A cluster randomized controlled trial evaluating two modes of CAPACITI program delivery: 1) self-directed learning, consisting of online access to program materials; and 2) facilitated learning, which also includes live webinars where the online materials are presented and discussed. The primary outcomes are 1) percent of patients identified as requiring palliative care (PC), 2) timing of first initiation of PC, and self-reported PC competency (EPCS tool). Secondary outcomes include self-reported confidence in PC, practice change, and team collaboration (AITCS-II tool), as well as qualitative interviews. Covariates that will be examined are readiness for change (ORCA tool), learning preference, and team size. Primary care teams representing interdisciplinary providers, including physicians, nurse practitioners, registered nurses, care coordinators, and allied health professionals will be recruited from across Canada. The completion of all three modules is expected to take participating teams a total of six months. DISCUSSION CAPACITI is a national trial aimed at behavior change in primary care providers. This research will help inform future palliative care educational initiatives for generalist health care providers. Specifically, our findings will examine the effectiveness of the two models of education delivery and the participant experience associated with each modality. TRIAL REGISTRATION ClinicalTrials.gov NCT05120154.
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Affiliation(s)
- Hsien Seow
- grid.25073.330000 0004 1936 8227Department of Oncology, McMaster University, Hamilton, ON Canada
| | - Daryl Bainbridge
- grid.25073.330000 0004 1936 8227Department of Oncology, McMaster University, Hamilton, ON Canada
| | - Samantha Winemaker
- grid.25073.330000 0004 1936 8227Department of Oncology, McMaster University, Hamilton, ON Canada
| | - Kelli Stajduhar
- grid.143640.40000 0004 1936 9465School of Nursing, University of Victoria, Victoria, BC Canada
| | - Gregory Pond
- grid.25073.330000 0004 1936 8227Department of Oncology, McMaster University, Hamilton, ON Canada
| | - Kathy Kortes-Miller
- grid.258900.60000 0001 0687 7127Department of Social Work, Lakehead University, Thunder Bay, ON Canada
| | - Denise Marshall
- grid.25073.330000 0004 1936 8227Department of Family Medicine, McMaster University, Hamilton, ON Canada
| | - Frances Kilbertus
- grid.436533.40000 0000 8658 0974Northern Ontario School of Medicine University, Thunder Bay, ON Canada
| | - Jeff Myers
- grid.17063.330000 0001 2157 2938Division of Palliative Care, University of Toronto, Toronto, ON Canada
| | - Leah Steinberg
- grid.17063.330000 0001 2157 2938Division of Palliative Care, University of Toronto, Toronto, ON Canada
| | - Nadia Incardona
- grid.17063.330000 0001 2157 2938Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
| | - Oren Levine
- grid.25073.330000 0004 1936 8227Department of Oncology, McMaster University, Hamilton, ON Canada
| | - Jose Pereira
- grid.25073.330000 0004 1936 8227Department of Family Medicine, McMaster University, Hamilton, ON Canada
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Seow H, Bainbridge D, Stajduhar K, Marshall D, Howard M, Brouwers M, Barwich D, Burge F, Kelley ML. Building Palliative Care Capacity for Generalist Providers in the Community: Results From the Capaciti Pilot Education Program. Am J Hosp Palliat Care 2022:10499091221134709. [PMID: 36269212 DOI: 10.1177/10499091221134709] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Primary care providers play an important role in providing early palliative care, however they often lack practical supports to operationalize this approach in practice. CAPACITI is a virtual training program aimed at providing practical tips, strategies, and action plans to help primary care providers offer an early palliative approach to care. The CAPACITI pilot program consisted of 10 facilitated, monthly training sessions, covering identification and assessment, communication, and engaging caregivers and specialists. We present the findings of an evaluation of the pilot program. Method: We conducted a single cohort study of primary care providers who participated in CAPACITI. Study outcomes were the change in the percentage of caseload reported as requiring palliative care and improved confidence in competencies measured on a 20-item, study-created survey. Pre and post survey data were analyzed using paired t-tests. Results: Twenty-two teams representing 127 care providers (including 36 physicians and 28 Nurse Practitioners) completed CAPACITI. Paired comparisons showed a moderate improvement in confidence across the competencies covered (.6 to 1.3 mean improvement across items using seven-point scales, all P < .05). Pre-CAPACITI, clinician prescribers (N = 32) identified a mean of 1.2% of their caseload requiring a palliative approach to care, which increased to 1.6% post-program (P = .02). Said differently, the total group of paired clinician prescribers identified 338 patients as requiring palliative care in their caseloads at baseline vs 482 patients following the intervention, for an overall increase of 144 patients in their collective caseloads. Conclusion: CAPACITI improved self-assessed palliative care identification and provider confidence in core competencies. The program demonstrated potential for building palliative care capacity in primary care teams.
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Affiliation(s)
- Hsien Seow
- Department of Oncology, 3710McMaster University, Hamilton, ON, Canada
| | - Daryl Bainbridge
- Department of Oncology, 3710McMaster University, Hamilton, ON, Canada
| | - Kelli Stajduhar
- Department of School of Nursing and Institute on Aging and Lifelong Health, 8205University of Victoria, Victoria, BC, Canada
| | - Denise Marshall
- Department of Health Sciences, 62703McMaster University, Hamilton, ON, Canada
| | - Michelle Howard
- Department of Family Medicine, 152996McMaster University, Hamilton, ON, Canada
| | - Melissa Brouwers
- School of Epidemiology and Public Health, 177403University of Ottawa, Ottawa, ON, Canada
| | - Doris Barwich
- 12358The University of British Columbia, Vancouver, BC, Canada
| | - Fred Burge
- Department of Family Medicine, 152980Dalhousie University, Halifax, NS, Canada
| | - Mary Lou Kelley
- School of Social Work, 157782Lakehead University, Thunder Bay, ON, Canada
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Pereira J, Meadows L, Kljujic D, Strudsholm T, Parsons H, Riordan B, Faulkner J, Fisher K. Learner Experiences Matter in Interprofessional Palliative Care Education: A Mixed Methods Study. J Pain Symptom Manage 2022; 63:698-710. [PMID: 34998952 DOI: 10.1016/j.jpainsymman.2021.12.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/09/2021] [Accepted: 12/31/2021] [Indexed: 12/17/2022]
Abstract
CONTEXT Interprofessional collaboration is needed in palliative care and many other areas in health care. Pallium Canada's two-day interprofessional Learning Essential Approaches to Palliative care Core courses aim to equip primary care providers from different professions with core palliative care skills. OBJECTIVES Explore the learning experience of learners from different professions who participated in Learning Essential Approaches to Palliative care Core courses from April 2015 to March 2017. METHODS This mixed methods study was designed as a secondary analysis of existing data. Learners had completed a standardized course evaluation survey online immediately post-course. The survey explored the learning experience across several domains and consisted of seven closed ended (Likert Scales; 1 = "Total Disagree", 5 = "Totally Agree") and three open-ended questions. Quantitative data were analyzed using descriptive statistics and Kruskal-Wallis non-parametric test tests, and qualitative data underwent thematic analysis. RESULTS During the study period, 244 courses were delivered; 3045 of 4636 participants responded (response rate 66%); physicians (662), nurses (1973), pharmacists (74), social workers (80), and other professions (256). Overall, a large majority of learners (96%) selected "Totally Agree" or "Agree" for the statement "the course was relevant to my practice". A significant difference was noted across profession groups; X2 (4) = 138; p < 0.001. Post-hoc analysis found the differences to exist between physicians and pharmacists (X2 = -4.75; p < 0.001), and physicians and social workers (X2 = -6.63; p < 0.001). No significant differences were found between physicians and nurses (X2 = 1.31; p = 1.00), and pharmacists and social workers (X2 = -1.25; p = 1.00). Similar results were noted for five of the other statements. CONCLUSION Learners from across profession groups reported this interprofessional course highly across several learning experience parameters, including relevancy for their respective professions. Ongoing curriculum design is needed to fully accommodate the specific learning needs of some of the professions.
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Affiliation(s)
- José Pereira
- Pallium (J.P., B.R., J.F.), Ontario, Canada; Division of Palliative Care, Department of Family Medicine (J.P.), McMaster University, Hamilton, Canada; Institute for Culture and Society (ICS) (J.P.), University of Navara, Pamplona, Spain.
| | - Lynn Meadows
- Department of Community Health Sciences (L.M.), Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dragan Kljujic
- Database Manager and Analyst (D.K.), Independent Consultant, Brampton, Canada
| | - Tina Strudsholm
- School of Health Sciences (T.S.), University of Northern British Columbia, Prince George, Canada
| | - Henrique Parsons
- Division of Palliative Care (H.P.), Department of Medicine, University of Ottawa; The Ottawa Hospital Research Institute Clinical Epidemiology Program; Bruyere Research Institute, Ontario, Canada
| | | | | | - Kathryn Fisher
- School of Nursing, Faculty of Health Sciences (K.F.), McMaster University, Hamilton, Canada
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Pereira J, Meadows L, Kljujic D, Strudsholm T. Do learners implement what they learn? Commitment-to-change following an interprofessional palliative care course. Palliat Med 2022; 36:866-877. [PMID: 35260018 PMCID: PMC9087309 DOI: 10.1177/02692163221081329] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care educators should incorporate strategies that enhance application into practice by learners. Commitment-to-change is an approach to reinforce learning and encourage application into practice; immediately post-course learners commit to making changes in their practices as a result of participating in the course ("statements") and then several weeks or months later are prompted to reflect on their commitments ("reflections"). AIM Explore if and how learners implemented into practice what they learned in a palliative care course, using commitment-to-change reflections. DESIGN Secondary analysis of post-course commitment statements and 4-months post-course commitment reflections submitted online by learners who participated in Pallium Canada's interprofessional, 2-day, Learning Essential Approaches to Palliative Care (LEAP) Core courses. SETTING/PARTICIPANTS Primary care providers from across Canada and different profession who attended LEAP Core courses from 1 April 2015 to 31 March 2017. RESULTS About 1063 of 4636 learners (22.9%) who participated in the 244 courses delivered during the study period submitted a total of 4250 reflections 4 months post-course. Of these commitments, 3081 (72.5%) were implemented. The most common implemented commitments related to initiating palliative care early across diseases, pain and symptom management, use of clinical instruments, advance care planning, and interprofessional collaboration. Impact extended to patients, services, and colleagues. Barriers to implementation into practice included lack of time, and system-level factors such as lack of support by managers and untrained colleagues. CONCLUSIONS Examples of benefits to patients, families, services, colleagues, and themselves were described as a result of participating in the courses.
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Affiliation(s)
- José Pereira
- Pallium Canada, Ottawa, Canada (Non-profit Foundation).,Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Canada.,Institute for Culture and Society (ICS), University of Navara, Spain
| | - Lynn Meadows
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Tina Strudsholm
- School of Health Sciences, University of Northern British Columbia, Prince George, BC, Canada
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Paal P, Müller A, Gil W, Goldzweig G, Elsner F. Nurturing Socioculturally and Medically Appropriate Palliative Care Delivery: Lessons Learned by Israeli Medical Faculty. JOURNAL OF RELIGION AND HEALTH 2022; 61:1469-1489. [PMID: 35262816 PMCID: PMC8967803 DOI: 10.1007/s10943-022-01522-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 06/14/2023]
Abstract
Israel is one of the few countries worldwide with a national policy and defined standards of palliative care (PC); its culture is highly diverse and more traditionally oriented in comparison with Western countries. This study describes the current state of PC in Israel through examination of: (1) its current status, self-image and structural factors; (2) its relation to cultural and political characteristics; and (3) the chances, goals and obstacles of advancing PC in Israel. Face-to-face interviews were conducted at all five public medical faculties in Israel from November 2017 to February 2018. The following findings are reported: (1) definition of palliative care, (2) multidisciplinary approach, (3) special role of nurses, (4) personal perceptions of death, (5) understanding the role of medicine, (6) specialty palliative medicine, (7) religious, spiritual and cultural aspects, (8) political and economic aspects, (9) obstacles and weaknesses, and (10) prospects and goals of palliative care. Participants perceive PC as an integrative healthcare service that should be available to all patients, including children and their families, at any stage of illness. They internalize that PC principles apply regardless of ethnic, cultural, and religious background. Utilizing nurses' leadership, enhancing multidisciplinary teamwork, and person-centered approach, supports better PC to more people.
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Affiliation(s)
- Piret Paal
- Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.
| | - Anne Müller
- Department of Palliative Medicine, RWTH Aachen University, Aachen, Germany
- Department for Internal Medicine, St. Elisabeth-Krankenhaus Geilenkirchen, Geilenkirchen, Germany
| | | | - Gil Goldzweig
- School of Behavioral Sciences, Academic College of Tel-Aviv-Yafo, Tel-Aviv, Israel
| | - Frank Elsner
- Department of Palliative Medicine, RWTH Aachen University, Aachen, Germany
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Juhrmann ML, Vandersman P, Butow PN, Clayton JM. Paramedics delivering palliative and end-of-life care in community-based settings: A systematic integrative review with thematic synthesis. Palliat Med 2022; 36:405-421. [PMID: 34852696 PMCID: PMC8972966 DOI: 10.1177/02692163211059342] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a growing demand for community palliative care and home-based deaths worldwide. However, gaps remain in this service provision, particularly after-hours. Paramedicine may help to bridge that gap and avoid unwanted hospital admissions, but a systematic overview of paramedics' potential role in palliative and end-of-life care is lacking. AIM To review and synthesise the empirical evidence regarding paramedics delivering palliative and end-of-life care in community-based settings. DESIGN A systematic integrative review with a thematic synthesis was undertaken in accordance with Whittemore and Knafl's methodology. Prospero: CRD4202119851. DATA SOURCES MEDLINE, CINAHL, PsycINFO and Scopus databases were searched in August 2020 for primary research articles published in English, with no date limits applied. Articles were screened and reviewed independently by two researchers, and quality appraisal was conducted following the Mixed-Methods Appraisal Tool (2018). RESULTS The search retrieved 5985 articles; 23 articles satisfied eligibility criteria, consisting of mixed-methods (n = 5), qualitative (n = 7), quantitative descriptive (n = 8) and quantitative non-randomised studies (n = 3). Through data analysis, three key themes were identified: (1) Broadening the traditional role, (2) Understanding patient wishes and (3) Supporting families. CONCLUSIONS Paramedics are a highly skilled workforce capable of helping to deliver palliative and end-of-life care to people in their homes and reducing avoidable hospital admissions, particularly for palliative emergencies. Future research should focus on investigating the efficacy of palliative care clinical practice guideline implementation for paramedics, understanding other healthcare professionals' perspectives, and undertaking health economic evaluations of targeted interventions.
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Affiliation(s)
- Madeleine L Juhrmann
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,HammondCare Centre for Learning and Research in Palliative Care, Greenwich Hospital, Greenwich, NSW, Australia
| | - Priyanka Vandersman
- Research Centre for Palliative Care, Death and Dying, Flinders University of South Australia, Adelaide, SA, Australia
| | - Phyllis N Butow
- Psycho-oncology Co-operative Research Group and Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, NSW, Australia
| | - Josephine M Clayton
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,HammondCare Centre for Learning and Research in Palliative Care, Greenwich Hospital, Greenwich, NSW, Australia
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Kaasalainen S, Mccleary L, Vellani S, Pereira J. Improving End-of-Life Care for People with Dementia in LTC Homes During the COVID-19 Pandemic and Beyond. Can Geriatr J 2021; 24:164-169. [PMID: 34484498 PMCID: PMC8390320 DOI: 10.5770/cgj.24.493] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
COVID-19 pandemic has resulted in a significant increase in deaths in long-term care homes (LTCH). People with dementia living in LTCHs represent one of the most frail and marginalized populations in Canada. The surge of COVID-19 cases in LTCHs and rationing of health-care resources during the pandemic have amplified the pre-existing need for improvements in palliative and end-of-life care in LTCHs. This position statement, created by a task force commissioned by the Alzheimer Society of Canada, provides recommendations for a multipronged coordinated approach to improving palliative and end-of-life care of people with dementia living in LTCHs during the COVID-19 pandemic and beyond.
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Affiliation(s)
| | - Lynn Mccleary
- Faculty of Applied Health Sciences, Nursing, Brock University, St. Catharines, ON
| | - Shirin Vellani
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON
| | - Jose Pereira
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, ON.,Pallium Canada, Ottawa, ON
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Pereira J, Giddings G, Sauls R, Harle I, Antifeau E, Faulkner J. Navigating Design Options for Large-Scale Interprofessional Continuing Palliative Care Education: Pallium Canada's Experience. Palliat Med Rep 2021; 2:226-236. [PMID: 34927146 PMCID: PMC8675227 DOI: 10.1089/pmr.2021.0023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 12/17/2022] Open
Abstract
To be effective, palliative care education interventions need to be informed, among others, by evidence and best practices related to curriculum development and design. Designing palliative care continuing professional development (CPD) courses for large-scale, national deployment requires decisions about various design elements, including competencies and learning objectives to be addressed, overall learning approaches, content, and courseware material. Designing for interprofessional education (IPE) adds additional design complexity. Several design elements present themselves in the form of polarities, resulting in educators having to make choices or compromises between the various options. This article describes the learning design decisions that underpin Pallium Canada's interprofessional Learning Essential Approaches to Palliative Care (LEAP) courses. Social constructivism provides a foundational starting point for LEAP course design, as it lends itself well to both CPD and IPE. We then explore design polarities that apply to the LEAP courseware development. These include, among others, which professions to target and how to best support interprofessional learning, class sizes, course length and content volume, courseware flexibility, regional adaptations, facilitator criteria, and learning methods. In some cases, compromises have had to be made between optimal perfect design and pragmatism.
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Affiliation(s)
- José Pereira
- Pallium Canada, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Institute of Culture and Society (ICS), University of Navarra, Navarra, Spain
| | - Gordon Giddings
- Pallium Canada, Ottawa, Ontario, Canada
- College of Physicians and Surgeons of Alberta, Edmonton, Alberta, Canada
| | - Robert Sauls
- Pallium Canada, Ottawa, Ontario, Canada
- Mississauga, Ontario (retired), Canada
| | | | - Elisabeth Antifeau
- Palliative Care End of Life Services, Interior Health, Vancouver, British Columbia, Canada
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Pereira J, Chary S, Faulkner J, Tompkins B, Moat JB. Primary-level palliative care national capacity: Pallium Canada. BMJ Support Palliat Care 2021:bmjspcare-2021-003036. [PMID: 34315718 DOI: 10.1136/bmjspcare-2021-003036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/11/2021] [Indexed: 01/29/2023]
Abstract
The need to improve access to palliative care across many settings of care for patients with cancer and non-cancer illnesses is recognised. This requires primary-level palliative care capacity, but many healthcare professionals lack core competencies in this area. Pallium Canada, a non-profit organisation, has been building primary-level palliative care at a national level since 2000, largely through its Learning Essential Approaches to Palliative Care (LEAP) education programme and its compassionate communities efforts. From 2015 to 2019, 1603 LEAP course sessions were delivered across Canada, reaching 28 123 learners from different professions, including nurses, physicians, social workers and pharmacists. This paper describes the factors that have accelerated and impeded spread and scale-up of these programmes. The need for partnerships with local, provincial and federal governments and organisations is highlighted. A social enterprise model, that involves diversifying sources of revenue to augment government funding, enhances long-term sustainability. Barriers have included Canada's geopolitical realities, including large geographical area and thirteen different healthcare systems. Some of the lessons learned and strategies that have evolved are potentially transferrable to other jurisdictions.
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Affiliation(s)
- Jose Pereira
- Family Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
- Pallium Canada, Ottawa, Ontario, Canada
| | - Srini Chary
- Pallium Canada, Ottawa, Ontario, Canada
- Division of Palliative Medicine, Foothills Hospital, Calgary, Alberta Health Services, Edmonton, Alberta, Canada
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Howard M, Hafid A, Isenberg SR, Hsu AT, Scott M, Conen K, Webber C, Bronskill SE, Downar J, Tanuseputro P. Intensity of outpatient physician care in the last year of life: a population-based retrospective descriptive study. CMAJ Open 2021; 9:E613-E622. [PMID: 34088732 PMCID: PMC8191591 DOI: 10.9778/cmajo.20210039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND For many patients, health care needs increase toward the end of life, but little is known about the extent of outpatient physician care during that time. The objective of this study was to describe the volume and mix of outpatient physician care over the last 12 months of life among patients dying with different end-of-life trajectories. METHODS We conducted a retrospective descriptive study involving adults (aged ≥ 18 yr) who died in Ontario between 2013 and 2017, using linked provincial health administrative databases. Decedents were grouped into 5 mutually exclusive end-of-life trajectories (terminal illness, organ failure, frailty, sudden death and other). Over the last 12 months and 3 months of life, we examined the number of physician encounters, the number of unique physician specialties involved per patient and specialty of physician, the number of unique physicians involved per patient, the 5 most frequent types of specialties involved and the number of encounters that took place in the home; these patterns were examined by trajectory. RESULTS Decedents (n = 359 559) had a median age of 78 (interquartile range 66-86) years. The mean number of outpatient physician encounters over the last year of life was 16.8 (standard deviation [SD] 13.7), of which 9.0 (SD 9.2) encounters were with family physicians. The mean number of encounters ranged from 11.6 (SD 10.4) in the frailty trajectory to 24.2 (SD 15.0) in the terminal illness trajectory across 3.1 (SD 2.0) to 4.9 (SD 2.1) unique specialties, respectively. In the last 3 months of life, the mean number of physician encounters was 6.8 (SD 6.4); a mean of 4.1 (SD 5.4) of these were with family physicians. INTERPRETATION Multiple physicians are involved in outpatient care in the last 12 months of life for all end-of-life trajectories, with family physicians as the predominant specialty. Those who plan health care models of the end of life should consider support for family physicians as coordinators of patient care.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont.
| | - Abe Hafid
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Amy T Hsu
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Mary Scott
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Katrin Conen
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Colleen Webber
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Susan E Bronskill
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - James Downar
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
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11
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Gallagher E, Carter-Ramirez D, Boese K, Winemaker S, MacLennan A, Hansen N, Hafid A, Howard M. Frequency of providing a palliative approach to care in family practice: a chart review and perceptions of healthcare practitioners in Canada. BMC FAMILY PRACTICE 2021; 22:58. [PMID: 33773579 PMCID: PMC8005234 DOI: 10.1186/s12875-021-01400-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/23/2021] [Indexed: 12/01/2022]
Abstract
Background Most patients nearing the end of life can benefit from a palliative approach in primary care. We currently do not know how to measure a palliative approach in family practice. The objective of this study was to describe the provision of a palliative approach and evaluate clinicians’ perceptions of the results. Methods We conducted a descriptive study of deceased patients in an interprofessional team family practice. We integrated conceptual models of a palliative approach to create a chart review tool to capture a palliative approach in the last year of life and assessed a global rating of whether a palliative approach was provided. Clinicians completed a questionnaire before learning the results and after, on perceptions of how often they believed a palliative approach was provided by the team. Results Among 79 patients (mean age at death 73 years, 54% female) cancer and cardiac diseases were the top conditions responsible for death. One-quarter of patients were assessed as having received a palliative approach. 53% of decedents had a documented discussion about goals of care, 41% had nurse involvement, and 15.2% had a discussion about caregiver well-being. These indicators had the greatest discrimination between a palliative approach or not. Agreement that elements of a palliative approach were provided decreased significantly on the clinician questionnaire from before to after viewing the results. Conclusions This study identified measurable indicators of a palliative approach in family practice, that can be used as the basis for quality improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01400-4.
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Affiliation(s)
- Erin Gallagher
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.,Division of Palliative Care, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Daniel Carter-Ramirez
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.,Division of Palliative Care, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Kaitlyn Boese
- Division of Palliative Care, Department of Medicine, University of Ottawa, 451 Smyth, Road Ottawa, Ottawa, ON, K1H 8M5, Canada.,Department of Palliative Care, Bruyere Continuing Care, 43 Bruyère St, Ottawa, ON, K1N 5C8, Canada
| | - Samantha Winemaker
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.,Division of Palliative Care, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Amanda MacLennan
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.,Division of Palliative Care, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Nicolle Hansen
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Abe Hafid
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.
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