The Situation

This large Canadian region is experiencing some of the fastest population growth in the country while at the same time experiencing the impacts of ageing demographics to the extent that it is expected that 23% of the population will be over the age of 65 by 2035. The mix of urban and rural settings has made it increasingly difficult to support patients and families who are challenged by the issues associated with the end of life. Multidisciplinary palliative care teams are available to support families however, it is a challenge to coordinate care especially given the timing and unpredictable needs of palliative patients. Families also often have several different contact numbers and coordinators of their care. Many families end up making repeated trips to emergency departments in order to receive care or to simply have questions answered.

The Solution

ASG, working with a team from the acute, home and palliative care settings along with patients and their families created an after-hours crisis line so that people would have one easy to access number to contact so that they could receive the care, support and information they needed. One thing the team did not want to do was create a single simple-to-reach program that would send all callers to the emergency department. To prevent this from occurring the ASG clinical team was granted access to each patient’s electronic clinical record and care plan. Each care plan had a stepped care approach to escalation which would allow the ASG nurse to use their clinical judgement supported by triage guidelines and a documented individualized care plan that all members of the circle of care could support. Based on the acuity of the patient’s need, the clinical guidelines and the care plan, ASG’s specialized registered nurses could manage the call entirely themselves, refer callers to their home care support team, their primary care provider, a palliative care physician or the Emergency Medical System (EMS). In order to complete the design and development of this cross-sectoral intervention, the parties completed a privacy impact assessment and generated all the necessary data sharing and consent management processes to ensure compliance with applicable health system privacy regulations. ASG registered nurses were also trained on the specifics of palliative care, the electronic record and the appropriate use of the circle of care. Finally, an evaluation framework was devised to support outcomes measurement.

The Impact

The initial pilot program received calls for pain and symptom management, followed by service referral, requests for health information, and equipment supply. At the time of the call, registered nurses triaged and answered questions, and if necessary, referred patients to an appropriate care provider. Over half of the issues were resolved during the call, and many patients were instructed on important self-care methods. 30% of the calls were referred back to home care case managers, and 4% of the calls resulted in a transfer to the hospital. The key to success was that the registered nurses could access the patient’s care plans at the time of the call. Pilot program designers anticipated that the majority of the calls would take place after hours, between 3 p.m. and 7 p.m. However, 40% of the call volume occurred during regular clinical business hours, on weekdays or weekends. Many of the calls came from family caregivers located inside the patient’s home. Several years after the launch of the pilot ASG continues to support the program which has become a tremendous example of the benefits of integrating virtual care into a traditional care delivery model.