Enhancing Palliative Care in Rural Ontario Using Integrated Community Palliative Care Bullet Rounds and Virtual Synchronous Visits

Background: Access to high-quality palliative care in rural Ontario is challenging due to limited health human resources and vast geographies, often resulting in potentially avoidable emergency department (ED) visits, unmet care needs and unfulfilled end-of-life preferences. Innovative integrated approaches to care are required to meet the needs of rural palliative patients.

 

Approach: In August 20205, health care system partners in a region of rural Ontario launched weekly integrated community palliative care bullet rounds (ICPCBR) and synchronous virtual visits (SVV) that were co-designed to enhance person-centered outcomes, and improve coordination and communication across health system partners. A patient partners and other system partners were engaged to identify opportunities to embed lived experience in the project design.

 

Intervention: ICPCBR brings together core healthcare service providers (i.e. palliative physicians, care coordinators, and community healthcare professionals) to succinctly discuss rostered patients and allow for critical sharing of information, care plan updates and risk mitigation. The rounds also include the prioritization and coordination of SVV between patients, palliative care physicians and homecare nurses that enhance both patient and provider experience by facilitating timely communication of concerning issues, support care delivery and education, and reduce the travel burden for patients and physicians by maximizing the in-home presence of nurses.

 

Evaluation The rounds are being evaluated through multiple metrics including, 1) care delivery action logs that document round discussions in six categories: care referrals, client and family education, staff education, care plan updates, scheduling, and health and safety issues, 2) patient outcomes related to ED visits and end-of-life preferences, and 3) staff, family, and caregiver experience and engagement surveys.

Results:

The volume of rostered patients from the initial palliative care physician grew from 14 patients in week one to 23 patients by week six of the year-long test of change, with an additional 24 patients from two palliative care physicians added by week seven.

 

In the initial six weeks, analysis of the six categories of action log data show that, on average, 3.4 (±1.3) categories were discussed on a patient’s first roster appearance while 2.8 (±2.8) categories were discussed per patient on average over the six weeks. The higher average for first roster appearance reflects more detailed discussions on the patient related primarily to staff and family/caregiver education (each 100% of the time) and care plan updates and referrals (each 87.5% of the time). The lower six-week average and higher standard deviation reflects a general stability in rounding with an acute need for in-depth rounding on some patients. Staff education (51.1%) and care plan updates (50%) were the most frequently discussed action items, followed by client/family education (39.2%), referrals (24.2%), health and safety (15.4%), and scheduling (11.5%).On-going data collection related to ED visits, patient outcomes, and stakeholder experiences are planned to demonstrate the impact of the ICPCBR on the quintuple aims of healthcare1.

 

Implications: Beyond expected patient care plan discussions and updates, ICPCBR play a critical role in the transfer of knowledge between healthcare professionals and identify important educational opportunities for patients and caregivers.