Visioning for secondary palliative care service hubs in rural communities: a qualitative case study from British Columbia's interior

Where to enhance rural palliative care? Developing a spatial model to identify suitable communities most in need of service enhancement

Background

In Canada, access to palliative care is a growing concern, particularly in rural communities. These communities have constrained health care services and accessing local palliative care can be challenging. The Site Suitability Model (SSM) was developed to identify rural “candidate” communities with need for palliative care services and existing health service capacity that could be enhanced to support a secondary palliative care hub. The purpose of this study was to test the feasibility of implementing the SSM in Ontario by generating a ranked summary of rural “candidate” communities as potential secondary palliative care hubs.

Methods

Using Census data combined with community-level data, the SSM was applied to assess the suitability of 12 communities as rural secondary palliative care hubs. Scores from 0 to 1 were generated for four equally-weighted components: (1) population as the total population living within a 1-h drive of a candidate community; (2) isolation as travel time from that community to the nearest community with palliative care services; (3) vulnerability as community need based on a palliative care index score; and (4) community readiness as five dimensions of fit between a candidate community and a secondary palliative care hub. Component scores were summed for the SSM score and adjusted to range from 0 to 1.

Results

Population scores for the 12 communities ranged widely (0.19–1.00), as did isolation scores (0.16–0.94). Vulnerability scores ranged more narrowly (0.27–0.35), while community readiness scores ranged from 0.4–1.0. These component scores revealed information about each community’s particular strengths and weaknesses. Final SSM scores ranged from a low of 0.33 to a high of 0.76.

Conclusions

The SSM was readily implemented in Ontario. Final scores generated a ranked list based on the relative suitability of candidate communities to become secondary palliative care hubs. This list provides information for policy makers to make allocation decisions regarding rural palliative services. The calculation of each community’s scores also generates information for local policy makers about how best to provide these services within their communities. The multi-factorial structure of the model enables decision makers to adapt the relative weights of its components.

A Scoping Review: Social Participation as a Cornerstone of Successful Aging in Place among Rural Older Adults

Despite obstacles, many rural-dwelling older adults report that positive aspects of rural residence, such as attachment to community, social participation, and familiarity, create a sense of belonging that far outweighs the negative. By being part of a community where they are known and they know people, rural elders continue to find meaning, the key to achieving successful aging in this last stage of life. This scoping review explored factors influencing social participation and, through it, successful aging among rural-dwelling older adults. We sought to answer the question: what factors enhance or detract from the ability of rural-dwelling older adults to engage in social participation in rural communities? The scoping review resulted in 19 articles that highlight the importance of supports to enable older people to spend time with others, including their pets, engage in volunteer and community activities, and help maintain their home and care for their pets. Overall, the lack of services, including local health care facilities, was less important than the attachment to place and social capital associated with aging in place.

Evaluating a model of delivering specialist palliative care services in rural New Zealand

INTRODUCTION Various methods of delivering specialist palliative care to rural areas have been discussed in the literature, but published evaluations of these models are sparse. This study surveyed the stakeholders of a rural specialist palliative care service (SPCS) to help identify potential gaps and inform planning regarding the future vision. METHODS A survey was sent to all relevant stakeholders across the West Coast of New Zealand, including staff in primary care, aged residential care and the hospital. It focused on understanding the local model of palliative care, the quality of the current service and perceived gaps. RESULTS Thirty-three per cent of the surveys were returned, from a cross-section of health-care providers. The medical respondents rated the quality of the service higher than nursing and allied health participants. All of the groups reported feeling the specialist palliative care team (SPCT) was under-resourced. Additional educational opportunities were considered essential. DISCUSSION Stakeholders found the service easy to access, but improvements in communication, educational opportunities and forward planning were identified as being needed. This information helps the West Coast SPCT plan its future direction and develop a higher-quality service that meets the needs of all stakeholders.

Community readiness and momentum: identifying and including community-driven variables in a mixed-method rural palliative care service siting model

BACKGROUND

Health service administrators make decisions regarding how to best use limited resources to have the most significant impact. Service siting models are tools that can help in this capacity. Here we build on our own mixed-method service siting model focused on identifying rural Canadian communities most in need of and ready for palliative care service enhancement through incorporating new community-driven insights.

METHODS

We conducted 40 semi-structured interviews with formal and informal palliative care providers from four purposefully selected rural communities across Canada. Communities were selected by running our siting model, which incorporated GIS methods, and then identifying locations suitable as qualitative case studies. Participants were identified using multiple recruitment methods. Interviews were transcribed verbatim and the transcripts were reviewed to identify emerging themes and were coded accordingly. Thematic analysis then ensued.

RESULTS

We previously introduced the inclusion of a 'community readiness' arm in the siting model. This arm is based on five community-driven indicators of palliative care service enhancement readiness and need. The findings from the current analysis underscore the importance of this arm of the model. However, the data also revealed the need to subjectively assess the presence or absence of community awareness and momentum indicators. The interviews point to factors such as educational tools, volunteers, and local acknowledgement of palliative care priorities as reflecting the presence of community awareness and factors such as new employment and volunteer positions, new care spaces, and new projects and programs as reflecting momentum. The diversity of factors found to illustrate these indicators between our pilot study and current national study demonstrate the need for those using our service siting model to look for contextually-relevant signs of their presence.

CONCLUSION

Although the science behind siting model development is established, few researchers have developed such models in an open way (e.g., documenting every stage of model development, engaging with community members). This mixed-method study has addressed this notable knowledge gap. While we have focused on rural palliative care in Canada, the process by which we have developed and refined our siting model is transferrable and can be applied to address other siting problems.

Palliating inside the lines: The effects of borders and boundaries on palliative care in rural Canada

We draw lines to divide our world into specific places, territories, and categories. Although borders and boundaries are dynamic and socially constructed, their existence creates many broad impacts on our lives by geographically distinguishing between groups (e.g., us/them; here/there; inside/outside) at various scales from the national down to the personal spaces of the individual. Particularly, borders and boundaries can be used to define a variety of differing spaces such as the familial, social, economic, political, as well as issues of access - including access to health services. Despite the implicit connection between borders, boundaries, and health, little research has investigated this connection from a health geography perspective. As such, this secondary thematic analysis contributes to addressing this notable gap by examining how borders and boundaries are experienced and perceived to impact access to palliative care in rural Canada from the perspectives of the formal and informal providers of such care. Drawing upon data from qualitative interviews (n = 40) with formal and informal palliative caregivers residing in four different rural Canadian communities, five forms of borders and boundaries were found to directly impact care delivery/receipt: political; jurisdictional; geographical; professional; and cultural. Implicitly and explicitly, participants discussed these borders and boundaries while sharing their experiences of providing palliative care in rural Canada. We conclude by discussing the implications of our findings for palliative care in rural Canada, while also emphasizing the need for more health geography, and related social science, researchers to recognize the significance of borders and boundaries in relation to health and healthcare delivery. Lastly, we emphasize the transferability of these findings to other health sectors, geographical settings, and disciplines.

Program assessment framework for a rural palliative supportive service

Although there are a number of quality frameworks available for evaluating palliative services, it is necessary to adapt these frameworks to models of care designed for the rural context. The purpose of this paper was to describe the development of a program assessment framework for evaluating a rural palliative supportive service as part of a community-based research project designed to enhance the quality of care for patients and families living with life-limiting chronic illness. A review of key documents from electronic databases and grey literature resulted in the identification of general principles for high-quality palliative care in rural contexts. These principles were then adapted to provide an assessment framework for the evaluation of the rural palliative supportive service. This framework was evaluated and refined using a community-based advisory committee guiding the development of the service. The resulting program assessment framework includes 48 criteria organized under seven themes: embedded within community; palliative care is timely, comprehensive, and continuous; access to palliative care education and experts; effective teamwork and communication; family partnerships; policies and services that support rural capacity and values; and systematic approach for measuring and improving outcomes of care. It is important to identify essential elements for assessing the quality of services designed to improve rural palliative care, taking into account the strengths of rural communities and addressing common challenges. The program assessment framework has potential to increase the likelihood of desired outcomes in palliative care provisions in rural settings and requires further validation.

Referral patterns and proximity to palliative care inpatient services by level of socio-economic disadvantage. A national study using spatial analysis

Background

A range of health outcomes at a population level are related to differences in levels of social disadvantage. Understanding the impact of any such differences in palliative care is important. The aim of this study was to assess, by level of socio-economic disadvantage, referral patterns to specialist palliative care and proximity to inpatient services.

Methods

All inpatient and community palliative care services nationally were geocoded (using postcode) to one nationally standardised measure of socio-economic deprivation – Socio-Economic Index for Areas (SEIFA; 2006 census data). Referral to palliative care services and characteristics of referrals were described through data collected routinely at clinical encounters. Inpatient location was measured from each person’s home postcode, and stratified by socio-economic disadvantage.

Results

This study covered July – December 2009 with data from 10,064 patients. People from the highest SEIFA group (least disadvantaged) were significantly less likely to be referred to a specialist palliative care service, likely to be referred closer to death and to have more episodes of inpatient care for longer time. Physical proximity of a person’s home to inpatient care showed a gradient with increasing distance by decreasing levels of socio-economic advantage.

Conclusion

These data suggest that a simple relationship of low socioeconomic status and poor access to a referral-based specialty such as palliative care does not exist. Different patterns of referral and hence different patterns of care emerge.

Variation in geographic access to specialist inpatient hospices in England and Wales

We seek to map and describe variation in geographic access to the set of 189 specialist adult inpatient hospices in England and Wales. Using almost 35,000 small Census areas (Local Super Output Areas: LSOAs) as our units of analysis, the locations of hospices, and estimated drive times from LSOAs to hospices we construct an accessibility 'score' for each LSOA, for England and Wales as a whole. Data on cancer mortality are used as a proxy for the 'demand' for hospice care and we then identify that subset of small areas in which accessibility (service supply) is relatively poor yet the potential 'demand' for hospice services is above average. That subset is then filtered according to the deprivation score for each LSOA, in order to identify those LSOAs which are also above average in terms of deprivation. While urban areas are relatively well served, large parts of England and Wales have poor access to hospices, and there is a risk that the needs of those living in relatively deprived areas may be unmet.

Be known, be available, be mutual: a qualitative ethical analysis of social values in rural palliative care

Background

Although attention to healthcare ethics in rural areas has increased, specific focus on rural palliative care is still largely under-studied and under-theorized. The purpose of this study was to gain a deeper understanding of the values informing good palliative care from rural individuals' perspectives.

Methods

We conducted a qualitative ethnographic study in four rural communities in Western Canada. Each community had a population of 10, 000 or less and was located at least a three hour travelling distance by car from a specialist palliative care treatment centre. Data were collected over a 2-year period and included 95 interviews, 51 days of field work and 74 hours of direct participant observation where the researchers accompanied rural healthcare providers. Data were analyzed inductively to identify the most prevalent thematic values, and then coded using NVivo.

Results

This study illuminated the core values of knowing and being known, being present and available, and community and mutuality that provide the foundation for ethically good rural palliative care. These values were congruent across the study communities and across the stakeholders involved in rural palliative care. Although these were highly prized values, each came with a corresponding ethical tension. Being known often resulted in a loss of privacy. Being available and present created a high degree of expectation and potential caregiver strain. The values of community and mutuality created entitlement issues, presenting daunting challenges for coordinated change.

Conclusions

The values identified in this study offer the opportunity to better understand common ethical tensions that arise in rural healthcare and key differences between rural and urban palliative care. In particular, these values shed light on problematic health system and health policy changes. When initiatives violate deeply held values and hard won rural capacity to address the needs of their dying members is undermined, there are long lasting negative consequences. The social fabric of rural life is frayed. These findings offer one way to re-conceptualize healthcare decision making through consideration of critical values to support ethically good palliative care in rural settings.

Aging in Rural Canada: A Retrospective and Review

La recherche sur le vieillissement en milieu rural s’est développée considérablement depuis la publication du livre,Aging in Rural Canada(Butterworths, 1991). Le but de cet article est double : de fournir une rétrospective sur les questions de viellissement en milieu rural tirée de ce livre, et une revue de la littérature canadienne sur le vieillissement en milieu rural depuis sa publication. L’examen met en évidence les nouvelles orientations dans les définitions conceptuelles du « rural », et dans les questions de l’engagement social, l’indépendance, les réseaux familiaux et sociaux et les services ruraux et la santé. Deux perspectives principales de recherche sont évidents. Le point de vue ou l’optique d’analyse de la marginalisation se concentre sur les personnes âgées en milieu rural ayant des problèmes de santé, mais n’a pas inclus celles qui sont marginalisées par la pauvrété ou le sexe. L’optique d’analyse du vieillissement sain se concentre sur les contributions et l’engagement, mais a omis la recherche sur les relations sociales et la qualité de l’interaction familiale. Le rapport comprend un appel s’interroger sur l’interaction entre les gens et leur lieu de vie et à comprendre les enjeux de la diversité en milieu rural et le processus de vieillissement en milieu rural.

'Heated political dynamics exist ...': examining the politics of palliative care in rural British Columbia, Canada

Palliative care is delivered by a number of professional groups and informal providers across a range of settings. This arrangement works well in that it maximizes avenues for providing care, but may also bring about complicated 'politics' due to struggles over control and decision-making power. Thirty-one interviews conducted with formal and informal palliative care providers in a rural region of British Columbia, Canada, are drawn upon as a case study. Three types of politics impacting on palliative care provision are identified: inter-community, inter-site, and inter-professional. Three themes crosscut these politics: ownership, entitlement, and administration. The politics revealed by the interviews, and heretofore underexplored in the palliative literature, have implications for the delivery of palliative care. For example, the outcomes of the politics simultaneously facilitate (e.g. by promoting advocacy for local services) and serve as a barrier to (e.g. by privileging certain communities/care sites/provider) palliative care provision.

A protocol for determining differences in consistency and depth of palliative care service provision across community sites

Numerous accounts document the difficulty in obtaining accurate data regarding the extent and composition of palliative care services. Compounding the problem is the lack of standardisation regarding categorisation and reporting across jurisdictions. In this study, we gathered both quantitative and spatial--or geographical--data to develop a composite picture that captures the extent, composition and depth of palliative care in the Canadian province of British Columbia (BC). The province is intensely urban in the southwest and is rural or remote in most of the remainder. For this study, we conducted a detailed telephone survey of all palliative care home care teams and facilities hosting designated beds in BC. We used geographic information systems to geocode locations of all hospice and hospital facilities. In-home care data was obtained individually from each of five BC regional health authorities. In addition, we purchased accurate road travel time data to determine service areas around palliative facilities and to determine populations outside of a 1-hour travel time to a facility. With this data, we were able to calculate three critical metrics: (i) the population served within 1 hour of palliative care facilities--and more critically those not served; (ii) a matrix that determines access to in-home palliative care measured by both diversity of professionals as well as population served per palliative team member; and (iii) a ranking of palliative care services across the province based on physical accessibility as well as the extent of in-home care. In combination, these metrics provide the basis for identifying areas of vulnerability with respect to not meeting potential palliative care need. In addition, the ranking provides a basis for rural/urban comparisons. Finally, the protocol introduced can be used in other areas and provides a means of comparing palliative care service provision amongst multiple jurisdictions.