Developing an integrated palliative remote care management program within Connected Care Halton OHT: Generating insights from cross-disciplinary experts

Background: The Regional Integrated Palliative Care Program (RIPCP) proposed by the Connected Care Halton Ontario Health Team (CCHOHT) is borne out of a growing demand for palliative care services within the Halton region. Problem: Data reviewed between 2019/20 and 2022/23 demonstrate the need to focus on palliative care within the Halton region, highlighted by the following key findings: 1) an 11.4% increase in the 65 years and older population, 2) over 50% of decedents with an initial palliative diagnosis are likely to visit the emergency department (ED) in the last 30 days of life, 3) a 13% increase in palliative patients who spend on average 25 days in hospital care, 4) over 50% of decedents are dying in hospitals, and 5) the healthcare cost for a hospitalized patient with palliative care needs is 20.38 times that of a patient cared for out of hospital. Program: The RIPCP seeks to address this recognized need by providing a comprehensive remote program that offers palliative care services from earlier stages in the disease trajectory up until end-of-life care with the hope of improving patients’ quality of life, and preventing crises and other challenges associated with ED visits and hospitalizations. The objective of the program is to provide a patient-centered care service that is tailored to individual patient needs including medical interventions and providing support in each patient’s preferred location. These are novel features of the program and they contrast with traditional models of palliative care that focus on a singular approach to end-of-life care. At the core of the program is monitoring of patient symptoms and providing timely interventions to avoid potentially critical situations and circumvent the need for ED visits and/or hospital admission. To ensure sustainment, the program will also rely on data analytics to measure relevant outcomes and identify trends to inform decisions. This program rests on the collaboration and coordination of activities among key partners within the region including CCHOHT’s RCM administrative staff, palliative care physicians, paramedics, IT services, a central intake referral system, home and community care support services, patients, families, and caregivers. The program’s target population includes individuals requiring palliative care services due to life-limiting illnesses, including those approaching end-of-life. This includes patients diagnosed with Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Cancer, and End Stage Renal Failure who have been identified as having palliative care needs. Questions: Now in its embryonic stage, the program coordinators seek feedback from specialists on the following questions related to the program: 1.What are some appropriate questions that can be posed to patients to assess patient experience and quality of end-of-life? 2.Are there any novel tools used to evaluate patient symptoms and quality of life that have proven useful in monitoring and managing burden of disease? 3.What other elements of integrated care can be incorporated into the program to improve program effectiveness? The outcomes of the conference discussion will inform planning evaluation of the palliative RCM program to ensure it meets principles of both palliative care and integrated care.