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Mandate
   The Clinical Nurse Consultant Team facilitates hospice palliative care consultation,
   education, mentorship and linkages to hospice palliative care resources across the
   continuum of care:

          • CCAC
          • Community Nursing & Support Agencies
          • Family Health Teams
          • Hospices (Residential & Community)
          • Long Term Care and Retirement Homes
          • Physicians


Program Criteria
   The following criteria inform admission to the HPC Teams Program:
  • Patients with a progressive life threatening illness and/or facing end of life
  • Primary intent of treatment is palliative whether palliation of disease or palliation of symptoms (physical, psychological, social)
  • Patient and family agree to the referral or to consultative support
  • DNR/No Code status is not required for entry into the program
  • Patient is having inadequately controlled pain or other significant symptoms related to their palliative diagnosis


Model diagram
HPC Model
Goals
   The Clinical Nurse Consultant Team will:

          • Develop /enhance geographic Interprofessional teams to provide comprehensive
            hospice palliative care across Central LHIN;

          • Provide education to increase the knowledge and skills of professionals
            providing in-home palliative care, including pain and symptom management,
            use of common assessment tools, community resources, collaborative
           care planning,Interprofessional documentation, the EDITH (Expected Death in
            the Home) and SRK (Symptom Relief Kit);

          • Engage and support stakeholders to increase their commitment to the provision of
             quality hospice palliative care;

          • Increase the percentage of client deaths in the setting of their choice;

          • Reduce the number of clients visiting the Emergency Department for Pain
            and Symptom Management;

          • Provide 24/7 availability of CNC consultation to members of the Interprofessional
             Team in person, by telephone or through e mail

Progress to Date
          • Interprofessional Rounds are established in each geographic area;
          • 8 CNC providing consultation in all areas of Central LHIN;
          • In-home chart developed and being implemented by the nursing service
            providers across Central LHIN;
          • Revised the EDITH protocol;
          • Revised the SRK;
          • Data base revised and electronic client record developed;
          • Provided education related to the Cancer Care Ontario Symptom Management
            Guidelines to CCAC. Nursing Agencies contracted by CCAC in Central LHIN.
          • Provided education to 43 Long Term Care Centres in Central LHIN to
            build capacity related to HPC



Current Activities



Interprofessional Rounds - in all areas of Central LHIN


Education to the Long Term Care home staff as requested



Calendar of Meetings
   • March 2019
   • February 2019



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