Regional Palliative Care Network of North Simcoe Muskoka

Toolkit

Educational Resources

 

 

  

 

 

 

 

 

 

 


 


 

 

 

About us

The Regional Palliative Care Network of North Simcoe Muskoka provides planning and strategic implementation of palliative care resources and services at the local level to ensure a system-wide approach to palliative care that’s patient focused.  It is made up of local partners such as home care agencies, hospitals, long term care, primary care, hospices and other organizations to improve palliative care for patients and families.

The Regional Palliative Care Network provides leadership, direction and structure to facilitate the development of a comprehensive, integrated and coordinated system of palliative care within the North Simcoe Muskoka Local Health Integration Network, which will support the provincial vision of hospice palliative care as outlined in Advancing High Quality, High Value Palliative Care in Ontario: The Declaration of Partnership and Commitment to Action.

 

The team

In September 2018, the Regional Palliative Care Network (RPCN) of North Simcoe Muskoka team was renewed and is now complete. The team includes Tara Moffatt, Director, who is dedicated to providing full-time oversight and coordination of planning and information analysis, developing relationships with local partners, and championing the importance of including palliative care in system planning, integration and sustainability for our health care system. She is also responsible for facilitating and leading the NSM Regional Palliative Care Network Steering Committee in collaboration with the Clinical Co-leads.  

The Clinical Co-leads -- Rebecca Ellerson and Dr. Kate McLachlin - are recognized leaders in palliative care and work in close partnership with Tara Moffatt to achieve regional initiatives. They have  in-depth and up-to-date knowledge of clinical and system level issues and the creation of strategies to address these issues across the region

The RPCN is accountable to the LHIN’s Chief Executive Officer and Cancer Care Ontario Regional Vice-President, who in turn are accountable to the Ontario Palliative Care Network and the Ministry of Health and Long-Term Care. Each of the 14 Regional Palliative Care Networks in Ontario is supported by a Network Director and two Multidisciplinary Clinical Co-Leads.

For more information on the Triad members, click here to read their full bios.

 

Our goals

  1. To provide recommendations for change to the NSM LHIN and the NSM Regional Cancer Program on the development of an integrated and coordinated system of palliative care.
  2. The NSM RPCN Steering Committee will support the provincial vision for palliative care as outlined in the Province’s Declaration (Advancing High Quality High Value Palliative Care in Ontario: A Declaration of Partnership and Commitment to Action).
  3. A palliative care system that is high quality, integrated and made for the patient.

 

Update- May 2019

The Ontario Palliative Care Network has recently released the Health Services Delivery Framework, Competency Framework, Early Identification and Goals of Care Resources in an effort to deliver on its Action Plan and transform our Palliative Care System. With the release of these documents, our collective work has only just begun. The implementation of the Delivery Framework and its supporting tools and frameworks, will require commitment, collaboration and resources at every level – provincial, regional and local – as we continue to work together to transform the delivery of palliative care in Ontario. Next steps for the RPCN in this collective effort include working with sub-regions and local sites to conduct a current state and readiness assessment against the model’s prioritized areas in order to provide new information about the status of interdisciplinary team-based palliative care, and inform potential future investments and policy changes. Our RPCN has been collaborating with the OPCN on these efforts through the Community Access to Palliative Care via Interprofessional Primary Care Teams Improvement Project (CAPACITI); and the palliative care inventories that the Sub-regional Palliative Care Working Groups have been completing across North Simcoe Muskoka this past year. Some additional successes and highlights for the RPCN and the Sub-regional Palliative working groups this past year include:

  1. Establishment of a Regional Transitions in Care Committee in collaboration and partnership with Royal Victoria Hospital (RVH). This committee’s purpose is to create an integrated regional network for hospice/palliative care to support the timely and safe transitions of palliative patients; and to link the internal (RVH) and external (regional partners) together throughout the continuum of care to improve the communication and coordination of palliative care across North Simcoe Muskoka.

  2. Establishment of the Regional Advanced Care Planning (ACP) Committee. This committee provides recommendations for change, education and knowledge transfer to stakeholders in the NSM LHIN including organizations, networks and individuals with regards to ACP, Health Care Consent, and Goals of Care Conversations that follows the Ontario Legal Framework.

  3. Creation of a RPCN website introducing the work of the RPCN, RPCN team member bios and contact information; recent work done in NSM pertaining to system level change in Palliative Care and a Tool box for health care providers/planners/leaders and residents of North Simcoe Muskoka about available education in Hospice Palliative Care, Evidenced based practices and Frameworks.

  4. Creation of a Regional Framework for Community Based Palliative Care Rounds. Community based rounds provides an opportunity for community-based palliative care team members which include all community partners to practice interdisciplinary collaboration and consultation.  Specifically, their purpose is to review current caseloads, identify clients who would benefit from a palliative approach to care and include revision of care plans accordingly; share knowledge regarding best practices, and provide a venue for interdisciplinary education.

  5. Creation of a DRAFT NSM Regional Palliative Approach to Care Decision Matrix tool.  This tool is intended to be used by Health Care Providers and Organizations to help them identify when a patient/client would benefit from a palliative approach to care; as well as complete a referral to specialized palliative care services.  The tool is based on the Gold Standards Framework, Pallium Canada and other Provincially, Nationally and Internationally recognized best practices in early identification.  The NSM regional tool also goes one step further and encourages providers to link their patients with local primary care and specialist palliative care teams in an effort to keep care locally and build capacity in local communities. The final version of this tool is expected to be released this year for implementation by local providers and organizations across NSM.

 

Finally, we would like to take a moment to acknowledge the amazing work by your Sub-regional Palliative Working Group this past Fiscal Year

 

  1. Couchiching- An extensive list of local primary, secondary and tertiary level palliative care providers and resources. This list of providers and resources will be utilized to identify current system level gaps, strengths and opportunities for building capacity in palliative care (including the implementation of the Delivery Framework, Competency Framework and Early Identification tool). In addition, the sub-region did excellent work in redesigning of local community palliative care rounds to ensure there is an effective platform for shared communication between key palliative care providers

     

  2. Muskoka- In addition to the inventory of local palliative care providers and services, Muskoka saw an incredible success in the planning and implementation of a secondary level Palliative Care Specialist Team within the South Muskoka Community.   24/7 Specialized Palliative Care services have become a reality for the community members of South Muskoka.  In addition, South and North Muskoka created and implemented a joint north and south community palliative rounds to better serve patients and families on bordering communities; as well as improve seamless care across the Muskoka sub-region.

     

  3. North Simcoe- similar to Couchiching, North Simcoe was extremely successful in pulling together a list of local primary, secondary and tertiary level palliative care providers and resources. In addition, from its inauguration in fall of 2018 North Simcoe Palliative Working Group has identified that the identification of patients in the emergency department whom would benefit from a palliative approach to care is a critical point in time to a) ensure wrap around palliative care services to residents of their community and b) work towards the MOHLTC current initiatives in “ending hallway health care”.  North Simcoe will be doing some critical work on implementing early identification tools in their community next fiscal year.

     

  4. South Georgian Bay- like the three previous sub-regions, SGB has also provided an inventory of primary, secondary and tertiary level providers in their sub-region.  In addition, it was recognized by SGB that the currently existing Shared Care Team Steering Committee would benefit from having the support of a larger group of system level Palliative Care leaders to comprise a Palliative Working Group within SGB. This group will address palliative care planning and implementation that is in alignment with NSM region and the province. Consequently, the Shared Care Team Members can continue to focus their work directly in the care of patients and their caregivers as a specialized team. The Shared Care Steering Committee with be a critical subgroup of the newly formed PWG. For more information on the Shared Care Team or the new SGB Palliative Working Group connect with Lynda Meeks, Interim Executive Director Hospice Georgian Triangle.

     

  5. Barrie and Area- the Barrie PWG has been working diligently over the past year on improving the palliative care system in Barrie and Area. Some initiatives include the creation of a Palliative Care Journal for Patients and Caregivers that is intended to identify the care team and their roles. In addition, the journal can be used as space for Health Care Providers to communicate to each other.

     

Continue to check back on the RPCN website for additional accomplishments of your RPCN and Sub-regional Palliative Working Groups.