3. Comprehensive team-based care
- Date: Thursday, September 19, 2019
- Concurrent Session B
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Time: 3:30pm-4:15pm
- Room: Pier 9
- Style: Presentation (information provided to audience, with opportunity for audience to ask question)
- Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
- Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations
Learning Objectives
Participants will be engaged in:
- Understanding the practical aspects of building an integrated palliative care team utilizing existing community resources with limited funding.
- Developing the infrastructure and support network to facilitate co-management of patients with life-limiting illness with the patient's primary care provider.
- Challenging agency bureaucracies to break down inter-agency barriers to integrated care.
- Building primary care provider capacity to identify patients earlier in their illness trajectory through education and the opportunity for consultation.
- Preventing caregiver burnout through system navigation and caregiver support.
Summary/Abstract
Timmins is a northern rural community with a population of 41,000 and limited palliative care services. These services are provided by several different community agencies and there is a lack of formal palliative care leadership. The need for intervention to improve palliative care efficiency and effectiveness was identified by a Timmins FHT primary care provider who felt that working together, we could improve the quality of life and experience for patients and families facing life limiting illness. Support was gathered from multiple service providers for a palliative team model that offered co-location at the Timmins FHT and in December 2017, the Timmins Integrated Palliative Care Team (TIPCT) was launched. The core team included a physician, Social Worker and Executive Director from the Timmins FHT, Home & Community Care NP and Care Coordinator and VON Pain & Symptom Management NP. Driving change and implementing a palliative care approach in Timmins has been a primary goal of the TIPC team. In addition, a simplified referral process has been created, education sessions for primary care providers have been developed and launched, care coordination has been enhanced through weekly palliative clinical bullet rounds, patient navigation is now provided through primary care and caregiver support and counselling through a Social Worker. This integrated model of care has the potential to be implemented in any community, particularly smaller, northern or rural, and for multiple programs and services. Local leadership through primary care has ensured that patient care needs are managed collaboratively through a team approach.
Presenter
- Jennifer McLeod, Executive Director, Timmins Family Health Team
- Celine Lamb, Nurse Practitioner / Pain & Symptom Management Nurse, Timmins Family Health Team / VON
- Ariane Flamain, Social Worker, Timmins Family Health Team
Authors/Contributors
- Jennifer McLeod, Executive Director, Timmins Family Health Team
- Celine Lamb, Nurse Practitioner / Pain & Symptom Management Nurse, Timmins Family Health Team / VON
- Ariane Flamain, Social Worker, Timmins Family Health Team