Hospice Palliative Care Network Project (HPCNet) Overview
What is the HPCNet Project? The Hospice Palliative Care Network Project (HPCNet) began in April 1999. During the past four years, the Project partners have developed and implemented an innovative model of home palliative care coordination and service delivery.
The HPCNet model of coordination and service delivery can serve as a template for home palliative care delivery throughout the province of Ontario.
The HPCNET Project is a joint effort of the Temmy Latner Centre for Palliative Care and the Toronto Community Care Access Centre, working with the Philip Aziz Centre, Bayview Community Hospice, Casey House Hospice, Community CARE Home Hospice and Trinity Home Hospice, and the Ontario Ministry of Health and Long-Term Care.
HPCNet Project GoalsThe specific goals of the HPCNet Project are to:
- Coordinate the interdisciplinary palliative care consultation services of community-based care providers, agencies, and health care institutions to enhance continuity of care;
- Reduce the suffering of persons who are dying and their families, through early referral and identification of problems;
- Develop uniform, evidence-based assessment tools for use during the initial consultation and in the daily care of patients and their families;
- Enhance the role, knowledge base and skills of physicians, nurses, home care coordinators, and volunteers who provide palliative care services.
Who has the Project cared for? The three Project teams have cared for more than 4,000 patients in the old city of Toronto since the Project began. Each of these patients has had access to the services of a specialist palliative care consultant physician, nurse, care coordinator, and hospice volunteer.
Approximately 60% of HPCNet patients are able to remain at home to die.
Through the Temmy Latner Centre for Palliative Care's Psychosocial Spiritual Program, support has been provided on an as-needed basis to as many patients and families as possible.
What has the HPCNET Project accomplished?
- Education is a core element of the consultative model. Team members have been working with primary care providers in the home and through formal education initiatives. Feedback received from participants in courses for care coordinators, nurses, and physicians indicates that the HPCNet modular sessions are effective and useful.
- A common patient chart, the Record of Care, has been developed in collaboration with thirty-three nursing, hospice and homemaking agencies. This Record has proven to be vital to collaboration, communication, and the development of integrated goals and care planning. The ROC has also been translated into French, through the support of the Toronto District Health Council.
- The need for reliable data and a means to access it from the community is critical to improving the continuity of care for palliative care patients. The Project has worked hard to develop a comprehensive database with a remote access interface. Currently, twenty-seven caregivers (including physicians, nurses, care coordinators, psychosocial spiritual counsellors, and hospice coordinators) are using a hand-held computer in the community.
- The Project has also developed policies and procedures, patient education materials, and a number of other useful resources. A CCAC resource booklet and multi-language patient information are tangible examples. Upon completion and evaluation, they will be made available as resource materials to the community.
- Well-integrated and coordinated care in the community requires a network of partnerships among primary and consulting care providers. HPCNet has been privileged to work with professionals and volunteers in providing quality care to palliative care patients in Toronto. These valuable relationships contribute to the innovative model of care that will provide increased benefit to patients.
What are the next steps for the Project? It is hoped that the Ministry of Health and Long-Term Care will support this model of service delivery that has been developed, implemented, and refined over the course of the past four years and that it will work with the palliative care community to implement regional programs based on the HPCNet model.
Evaluation of the model has been on-going throughout the Project both by the Project committee and an external evaluator. The internal evaluation is concerned with service delivery, educational initiatives, and team function; initial assessments are included in the project description.
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More information
HPCNet Project Description :
Please note that this document will be revised on an ongoing basis. Please check this page again for updates to
the document.
HPCNet Project Description(PDF, 1MB)
HPCNet Project Key Messages:
This interdisciplinary chart is designed to support sharing of information among all members of the patient's Care Team, including
the patient's family, in order to better manage and address the patient's concerns and needs in his/her home.
This advantage will assist the Care Team in developing a Care Plan that is directed by and focused on the patient's needs.
HPCNet Project Key Messages (PDF, 121KB)
Record of Care:
What the Record of Care (ROC) is all about
- This interdisciplinary chart is designed to support sharing of information among all members of the patient's Care Team, including the patient's family, in order to better manage and address the patient's concerns and needs in his/her home. This advantage will assist the Care Team in developing a Care Plan that is directed by and focused on the patient's needs.
- This chart is a legal document that is shared by all professional and non-professional service providers involved in the patient's care.
- The Record of Care (ROC) chart is introduced into the home by the HPCNet Team.
- The patient, family, friends and all Care Team members are encouraged to document in this chart in order to improve communication among all members of this team.
- We acknowledge the patient's need to direct and participate in his/her plan of care decisions.
- We acknowledge the patient's need to direct and participate in his/her plan of care decisions.
- We want to ensure that patient has input into the decisions that are made concerning his/her care, as this directly affects a patient's quality of life outcomes.
- The Record of Care will remain in the home for the duration of the patient's services with the HPCNet and the Toronto Community Care Access Centre.
- The ROC chart is returned to the Toronto Community Care Access Centre on discharge of patient services and will be held as according to Ministry of
Health regulations related to patient health records.
This ROC chart will help to:
- Communicate with people who come into the patient's home.
- Help schedule visits in the home and appointments with providers and clinics.
- Facilitate communication of patient concerns by providing a chart in which all members of the care team can document.
- Provides a means whereby the patient and family can readily identify problems and record these for further follow-up by the service providers.
- Keeps a record of the essential contacts and phones numbers of the Care Team.
A Care Team may include any combination of the following:
Family, Friends, Doctors, Nurses, Social Workers, Care Coordinators, Unregulated Care Providers, Hospice Volunteers, Church groups, Spiritual Advisors
To view the pages of the Record of Care :
Section 1
Introduction (Contact Forms, Acknowledgements, Table of Contents, Record of Care Description, Appointment Calendar)
Section 2
Contact Numbers, Demographics, Initial Clinical Assessment Tool
(Demographic Sheet, Advance Care Planning Sheet, Medication List, Allergy Sheet)
Section 3
Patient, Family & Friends
(Regular Tests & Treatment List, Pain Scale, Bowel Routine)
Section 4
Patient Care Plan (Patient & Family Concerns)
Section 5
Interdisciplinary Care Team Section (Sign-in Sheet, Communication Record to TCCAC Coordinator, UCP and Volunteer Activity Sheet and Report Record,
Clinical Assessment Flow Sheet, Care Team Progress Notes, Doctor's Order Sheet)
Section 6
Medication Section
(Allergy and Adverse Reactions Sheet, Medication Administration Record, Regular and PRN Medication List)
Section 7
Assessment Forms/Extra Forms (Initial Assessment Tool for Nausea & Vomiting, Initial Pain Assessment Tool, Initial Respiratory Symtoms Assessment Tool,
Clinical Assessment Flow Sheet, Generic Form, KCI Theraputic Surface Assessment Tool, Mouth Care Assessment Tool & Flow Sheet,
Nausea and Vomiting Flow Sheet, Ostomy Care Plan, Equipment, Pain Monitoring Flow Sheet, Wound Assessment Flow Sheet)
Section 8
Reference Section
(Infection Precautions/Warnings, Opioid Analgesics, PCUs in Hospitals, Hospice Fact Sheet and Forms, Referral Form for Psychosocial Team at the
Temmy Latner Centre for Palliative Care, Last Hours, Sample Medical Supply Lists and Order Forms, Last Hours, References)
Dossiers de soins:
Qu'est-ce que le Dossier de soins?
- Le présent Dossier de soins est conçu pour faciliter le partage d'informations entre les membres de votre équipe de soins, y compris vous et votre famille,
afin de gérer vos besoins et préoccupations et de mieux en tenir compte, ce qui nous aidera à dresser un Plan de soins axé sur vos besoins.
- Le présent Dossier de soins est un document de nature légale que se partagent les fournisseurs de services pro-fessionnels
et non professionnels et qui doit être retourné au Centre d'accès aux soins communautaires de Toronto lorsque la prestation des services au patient cesse.
- Nous sommes conscients de votre besoin d'orienter la planification de vos soins.
- Nous voulons nous assurer que vous participez à la prise de décisions concernant vos soins.
- Le présent Dossier de soins devrait être laissé à domicile pour être utilisé par vous-même, votre famille, vos amis et votre équipe
de soins pour toute la période pendant laquelle vous recevez des services de HPCNet et du Centre d'accès aux soins communautaires de Toronto.
- Veuillez placer le Dossier de soins dans un lieu sûr et accessible par l'équipe de soins.
- Veuillez écrire lisiblement et gardez le présent Dossier de soins à jour.
Le présent Dossier de soins vous permettra:
- De communiquer avec les personnes qui se rendent à votre domicile.
- De prendre rendez-vous avec les personnes qui doivent se rendre à votre domicile.
- De prendre immédiatement note de vos préoccupations au moment où vous y pensez.
- D'avoir sous la main les noms et numéros de téléphone des membres de votre équipe de soins.
Votre équipe de soins peut se composer:
De vous-même , De médecins , D'infirmières , De coordonnateurs de soins, De bénévoles en soins palliatifs , De votre famille et de vos amis, De thérapeutes, De travailleurs sociaux, De fournisseurs de soins non réglementés, De conseiller(s) spirituels(s)
Pour visualiser les pages du Dossiers de soins
Section 1
Introduction
(Remerciements, Table des matières, Projet HPCNet, Qu’est-ce que le Dossier de soins?, Votre équipe de soins, Calendrier de rendez-vous)
Section 2
Données démographiques
(Ce formuliare doit être rempli par l'équipe de HPCNet en collaboration
avec le patient et sa famille.)
Outil d'évaluation clinque initiale
( Les autres outils d'évaluation initiale se trouvent à la Section 7. Une
fois remplis, tous ces outils doivent être versés dans la présente section.)
Section 3
Patient, famille et amis
(Reseignements pour le patient, la famille et les amis; Liste des examens et des traitements courants;
Notes du patient, de la famille et des amis; Gestion de la douleur; Éliminations intestinales du patient.)
Section 4
Plan de soins du patient
(Ce plan doit être préparé par le patient et la famille avec l'aide de
l'equipe de soins.)
Section 5
Équipe de soins interdisciplinaires
(Formulaires utilises régulièremet: Registre [à chaque visite]; Feuille d'activities [PSNR], les bénévoles en soins palliatifs et les autres bénévoles;
Compte rendu des fournisseurs de soins non réglementés [PSNR], des bénévoles en soins palliatifs et des autres bénévoles; Feuille d'évaluation clinque;
Notes d' évolution de l'equipe de soins interdis-
ciplinaires; Feuille des prescriptions médicales.)
Section 6
Médicaments
(Formulaires utilisés régulièrement: Allergies et réactions indésirables
[formulaire jaune]; Liste des médicaments ordinaires et PRN)
Section 7
Outil d' évaluation et formulaires supplémentaires
(Outil d'évaluation clinique initiale - nausée et vomissements, Outil d'évaluation initiale de la douleur; Outil d'évaluation initiale des symptômes respiratoires,
Feuille d'évaluation clinique, Formulaire universel, Outil d'évaluation des surfaces thérapeutique KCI, Outil et Feuille d'évaluation des soins de la bouche;
Feuille pour nausée et vomissements, Plan de soins - Stomie, Feuille d'évaluation de la douleur, Feuille d'évaluation des plaies)
Section 8
Référence
(Précautions contre les infections à l'intention des fournisseurs de soins, Analgésiques opioïdes, Unités de soins palliatifs, Les soins palliatifs à Toronto,
Formulaire d'aiguillage - Èquipe psychosociale du Temmy Latner Centre for Palliative Care, Exemples de listes de fournitures, Liste complète des documents de référence du Dossier de soins)
La permission est accordée d'utiliser les Dossiers de Soins dans la mesure où sont reconnus "L'Hospice Palliative Care Network Project" et ses partenaires, "The Temmy Latner Centre for Palliative Care" et "The Toronto Community Care Access Centre." Back to top |
