transforming seniors care - vch

COMMUNITY ENGAGEMENT

Joint Community Health Advisory Committee Meeting

October 4, 2008North Vancouver, BC

Discussions on

Transforming Seniors Care

Table of Contents

1. Summary............................................................3 2. Participants........................................................4 3. Invitation ............................................................5 4. Background Material ........................................7 5. Reports...............................................................12

1. What effective community partnerships will reduce the reliance/congestion on the ED?

2. How do we ensure timely check in with patient after leaving hospital to make sure they are progressing?

3. Aboriginal Peoples streaming through system and discharge planning

4. Understanding and accepting my medical diagnosis 5. How do we ensure good care / good outcomes for people who can’t

speak for themselves? 6. Elder Facilities/Services in the Central Coast 7. Community reintegration: Preparing the caregiver 8. Process / flow chart through an episode of care 9. Family help in the hospital 10. How do we make the emergency staff / facilities more Aboriginal

friendly to promote access of services? 11. While in ED, practical issue of toileting the older patient 12. How to assist / facilitate patients and family members advocating

for the care they want / need? 13. End of Life Palliative Care: Aboriginal Cultural Needs 14. Medications: how can we help you get the most out of them and

take them safely? 15. Support from VCH to build an Elder Care Centre

6. Priority List ........................................................40 7. Evaluation..........................................................41

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1. SUMMARY The Vancouver Coastal Health Joint Community Health Advisory Committees held a meeting on Saturday, October 4th 2008 to join with members of the Senior Executive Team to discuss “Transforming Seniors Care”. The event was hosted by the Coastal Community Advisory Committee at Lions Gate Hospital, North Vancouver. Since the theme “Transforming Seniors Care” is one of the key transformative strategies, members of the Continuums Team were also in attendance. The combination of Seniors Executive Team, Directors from the Continuums Team and members from the four VCH Advisory Committees ensured lively discussion. 49 people participated in the day long session. The Open Space technique proved to be an excellent format to promote discussion on varied topics that focused on the question: “How can the patient, family and public help to improve outcomes for seniors who come into the hospital?” The results of the 15 discussion groups were compiled into reports that were read later in the day. The reports were then prioritized by the group to determine which should be addressed first by the Continuum team. Senior staff committed to taking these reports to their planning tables and involving the Community Engagement Team and members of the Community Health Advisory Committees in identifying the next steps. The reports from each of the discussion groups are included in this report and all of the participants received a copy. The process of the day successfully fulfilled the goal to provide advice on how to engage patients, families and public in the implementation of this VCH strategy.

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2. Participants Judith Berg Barbara Greenlaw Corisande Percival-Smith

Shannon Berg Wilma Hallam Sheila Pither

Leonard Bob Anne Harvey Geoff Pross

Belinda Boyd Farahnaz Heidarpour; Norma Roberts

Nancy Breton James Hsieh Zarina Sajoo

Duncan Campbell Hilary King Leslie Sam

Nick Chopra Manabu Koshimura Linda Schwartz

Mel Clark Caleb Lee Anne Sutherland Boal

Alison Cormack Myrna Leishman Karmel Tanner

Sue Davis Rick Linger David Thompson

Linda Day Ann Mackie Margreth Tolson

Diana Day Heather Manson Roberta Tottle

Jane De Lemos Teresa Marconato Patricia Turner

Louise Donald Teresa McCausland Peter Vlahos

Hatem Ela-Alim Lynda McCloy De Whalen

Richard Eschelmuller Janet McElhaney

Anna Glaze Debbie Nider

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3. Invitation


Context: Each Year the VCH CHAC (Community Health Advisory Committees) join SET (Senior Executive Team) to provide feedback on topics of mutual interest and to provide and opportunity for public input in SET decision making. It also provides an opportunity for the CHAC/CAC to take action on the issue in their local communities, in support of VCH goals. Theme: SET has suggested that one area of focus is “Transforming Seniors Care” as this is one of the key transformative strategies and so this will be the theme for the Fall Joint CHAC meeting. The event will be hosted by the Coastal Community Advisory Committee who met with other CHAC members and senior staff to plan the day. Participants: All members from the four VCH Advisory Committees will be invited and all members of SET. In addition, representatives from the Continuums portfolio, especially those leaders responsible for regional strategies for senior’s care, will be in attendance. Outcome: The main goal for the day will be to provide an opportunity for participants to benefit from everyone’s experience and knowledge and by the end of the day to identify some priorities for future actions as they relate to the question: “How can the patient, family and public help to improve outcomes for seniors who come into the hospital? The Agenda: The agenda for the conversations at the Joint Meeting will be created by the participants and their perception of the challenges and opportunities for “Transforming Seniors Care”. Using an “Open Space” technique for the day, participants will take responsibility for reporting their ideas and suggestions. The Open Space approach will allow for focus on those issues for which participants have a passion to discover solutions and strategies. Open Space is a means of holding meetings that develop open communication. The theme for session is "Transforming Seniors Care" and the key question that will guide the choice of topics for the discussions is: “How can the patient, family and public help to improve outcomes for seniors who come into the hospital? The participants, CHAC and staff, have an opportunity to post on the wall, topics they feel are important and related to the theme. This creates the agenda for the discussions. Participants will choose three group sessions to attend. The group discussions are recorded and posted for everyone to read and at the end of the day a priority setting exercise will identify the top five topics that will be given to the Continuums team to help inform their action plans in the future. All of the documented material is available to all participants. Givens for the event: This session does take place within some boundaries. The theme will relate only to seniors as they enter the system through the emergency room and the attempts made to reduce the decline in function that 33% of seniors experience with an acute care admission.

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Preparation: Please read the attached:

• Transforming Seniors Care-Overview of the Project • Implementation Plan and Status

Time frame for the day:

9:00 Welcome, coffee, registration 9:15 Opening Statements- Ida Goodreau (Coastal M.C. BG will introduce) 9:30 Outline of the purpose for the day 9:35 Introduce Open Space and create the agenda (Facilitator, HK) 10:00 Discussions - 1 10:45 Discussions - 2 11:30 Discussions - 3 12:15 Lunch 1:15 Circle - Process for choosing Priorities 1:30 Reading of Reports 2:00 Break 2:15 Choices for Priorities 2:30 Naming the top five priorities and next steps 2:40 Evaluation and Closing Circle 3:00 End of Session

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4. Background material Transforming Seniors Care – Overview of Project

The purpose of the Transforming Seniors Care project is to improve care for older

adults (age 70+ years) throughout Vancouver Coastal Health and Providence Health Care. The goal is to reduce length of hospital stay, and to promote discharge home instead of other levels of care (i.e. assisted living or residential care). Seniors are especially at risk in acute care; approximately one-third of older adults experience decline in function during an acute care (i.e. hospital) stay. They are hospitalized three times as often as their younger counterparts. At discharge, one-third will never recover to their previous level of independence, increasing the risk of further decline in activities of daily living (ADL) (i.e. dressing, bathing, walking, eating). In the 65+ age group, 5% die during hospitalization, and 20-30% die within a year after discharge.

Fig 1 – Dynamic Frailty: Possible Consequences of an acute event on an older adult are shown in the graphic below. During an acute episode, an older adult may appear temporarily frail. With the appropriate care, that person can return to function and the normal aging process. Without this, the person may remain frail or become more frail.

The Project Focus

The Transforming Seniors Care Project is based on evidence based interventions

that improve health outcomes for seniors. Also, similar projects have been successfully implemented in other parts of Canada. Dr. Janet MacElhaney, who is the Regional Medical Director for Seniors and is also the Division Head of Geriatric Medicine for UBC, Providence Health Care and Vancouver Acute has implemented an interdisciplinary team with a similar approach in Edmonton from 1991-1998 and achieved significant results.

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This approach has also been implemented in our own health authority (ie. a unit at VGH and a unit at St. Paul’s) with significant results so we know it can be done in our own health authority.

The Project focuses on five main areas of older adult care: urinary catheterization,

mobility, nutrition/hydration, medication use, and delirium. Each is covered in a guideline that identifies goals of care and practice strategies for each issue. Also, the guidelines allow the ability for various health service delivery areas and entities to individualize their approach to management of these focus areas.

Catheterization.

Urinary catheterization is very common in acute care. For example, it is used for specimen collection, and in the case of urinary retention. However, indwelling catheters are frequently used without a specific indication. The result of such use creates a risk for urinary tract infection, bladder spasms, trauma, and ultimately urinary incontinence when the catheter is removed. In addition, catheter use is a risk factor for developing cognitive impairment, dependence in 1-3 activities of daily living and for not achieving the mobility necessary to prevent loss of muscle mass. The risk for obtaining one or more of these potential complications is apparent within 48 hours of catheter insertion.

The Catheter Use Guideline proposes:

That healthcare professionals use appropriate criteria for indwelling catheterization (i.e. for surgical procedures, chronic urinary retention)

That transient causes of incontinence, like fecal impaction or dehydration, are resolved, and care practices are catered to preventing catheter-associated complications (i.e. appropriate care and cleaning, frequent changing if necessary, and earliest removal as the highest priority)

That a reminder system to track duration of catheterization is implemented Functional Mobility Related to an Acute Event

Functional mobility is a major component of independent living, and a major threat to maintaining mobility is an acute event, hospitalization, and the 3-month period following hospitalization. The decline in mobility is primarily attributed to prolonged periods of inactivity and bed-rest; adverse medication effects, pain, malnutrition and dehydration all contribute to immobility.

Older adults can lose up to 5% of functional muscle for each day that they are largely confined to bed; hence, older patients are encouraged to be out of bed from the first day of hospitalization as prolonged inactivity is associated with decline in overall function, delirium, pressure ulcers, incontinence, and falls. Cluttered hallways, medical devices (i.e. catheter tubing, IV’s), lack of hand-rails or grab-bars, beds in high positions, physical restraints all contribute to immobility and bed rest in the acute setting.

The Mobility Guideline proposes: That appropriate assessment and goals are set with clients who present with an

acute illness/episode That there should be an interdisciplinary approach to care delivery – involving all

health professions in improving and assessing functional mobility An emphasis on discharge planning with appropriate follow up with client and

family/caregivers post-discharge from hospital Enhanced communication between care providers within and across care

continuums

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Nutrition and Hydration Since malnutrition can have various meanings, malnutrition and dehydration within

this guideline focuses on inadequate intake of nutrients and fluids. Older adults are particularly vulnerable to malnutrition and dehydration, not only because of natural age-related changes, like diminished protein reserves and a decrease in body water composition, but also because it can be a cause or an effect of an illness. 25-50% of hospitalized older adults experience malnutrition. Malnutrition is an independent risk factor for increased length of stay in hospital, and dehydration is a significant risk factor for delirium.

The Nutrition and Hydration Guideline proposes:

Assessing nutritional status on admission to hospital and monitoring as appropriate Instituting interdisciplinary interventions to promote and facilitate adequate nutrition

and oral intakes Promote communication between different health services by documenting

discharge and transfer form about nutrition/hydration status for appropriate follow-up

Medication

Medication adverse events (i.e. side-effects, taking wrong medication) can occur for many reasons; however, over half of all hospital medication errors occur at the interfaces of care – when a patient is transferred between healthcare services, discharged home for follow-up at a later date, on admission, etc. Most common medication discrepancies are: omission of a common medication, conflicting information from different sources (i.e. different dose indicated), discharge instructions were incomplete/illegible/inaccurate, duplications of medications, or incorrect labels.

The Medication Guideline proposes:

Obtaining best medication history from patients/caregiver on admission, bringing any discrepancies to the physicians attention

Ensuring that appropriate medication orders are given at discharge. Communicate the information to the next health service to prevent drug events post-discharge. Also educate the patient and family regarding the prescribed medications.

Improving medication management by using appropriate medications for older adults when managing pain, insulin treated diabetes, and insomnia.

Delirium

Delirium is the temporary disturbance in consciousness, attention, cognition, memory, and perception. The main causes of delirium are: nutritional deficits, fluid disturbances (i.e. dehydration), infections, medications, and hypoxia (low oxygen levels). If it is left untreated, it can lead to functional and cognitive decline, and contribute to increased length of hospital stay, discharge to other level of care (i.e. another hospital, residential care) and even can contribute to early death.

The Delirium Guideline proposes:

Identify potential risk factors to prevent delirium, and use appropriate assessment tools to promote early identification, and treat the underlying cause of delirium – while using minimal restraints and maximizing mobility

Involve the family in identifying delirium and helping with management

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Implementation Plan and Status ( as of August 29, 2008) Changing clinical practice should be easy, since all healthcare professionals want to do the best for the patients in their care. Unfortunately, heavy workload and competing priorities in the daily schedule of many health care providers create a disincentive to changing the way they have always delivered care. Therefore the following aims and activities have been built into the implementation plan.

Aim: Description of Activities Status 1) Support from

senior operations management:

Once the Senior Executive Team approved the project, launch meetings were held with each COO and the CEO of Providence and their senior leadership teams. The purpose was to gain their support and receive direction on how to implement within their local change management structures/projects.

Status: Complete

2) Ensure

alignment with other transformation and redesign initiatives:

A series of meetings has been held with the key leaders for all transformation and re-design projects which might overlap with this project. Agreements have been secured on how to align the projects and understand results.

Status: Mostly complete. One final meeting scheduled for mid -September

3) Support and

alignment from professional practice:

Professional Practice functions in a matrix relationship with operations, so it was important to ensure support and alignment with their work. Support was received from the Executive Lead – Professional Practice and Chief Nursing Officer. A series of meetings were then held with all the regional and local discipline and interdisciplinary councils to receive their support and advice on implementation.

Status: Mostly complete. Professional practice and other key stakeholders signed off on guidelines August 19, 2008. 90% of launch meetings complete.

4) Support and alignment with patient safety professionals:

A launch meeting was held with the VP- Patient Safety and his team. Support was obtained and advice received on aligning the project with their work and on data collection.

Status: Complete. Launch complete and will liaise throughout project.

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5) Customize the

implementation plan to build on local priorities and existing work:

The implementation of these guidelines are being customized by site to build on local work and priorities with the understanding that all will be implemented by the end of the 2 year project. Some HSDA’s are deciding to start with one guideline because they are already working on that area, while others are ready to go for all but the start may be only in defined units.

Status: In process. Should be complete by end September.

6) Use of evidence

based methodology to change practice and sustain the change.

An evidence based methodology to change existing practice and sustain change is being used to support implementation. The methodology has been developed by the Institute of Healthcare Improvement (IHI) and the model has been shown to be effective. The model is based on collaborative learning sessions for staff and is supported by the use of local, short cycle monitoring and revision at the unit level. The local, short cycle monitoring is based on the “Plan, Do, Study, Act” approach ( known as PDSA cycles) which means the team can quickly see the results of their work and quickly implement change as needed.

Status: In process. Designing this with local units. Should be complete by end September.

7) Involvement of

patients, families and caregivers in implementation:

The literature has shown that if patients, families and caregivers are informed participants in their care that outcomes are improved. The team are seeking advice from the Joint Community Health Advisory Committee about how to engage/inform patients, families and caregivers and the public (ie. potential patients, families and caregivers) about this project.

Status: Meeting planned Oct 4, 2008 with Joint CHAC for discussion and advice.

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5. Reports

COMMUNITY ENGAGEMENT

Joint Community Health Advisory Committee Meeting

October 4, 2008 North Vancouver, BC

Discussions on


“How can the patient, family and public help to improve outcomes for seniors who come into the hospital?”

Book of Reports

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How can the patient, family and public help to improve outcomes for seniors who come into

the hospital? __________________________________________________________________

TOPIC: What effective community partnerships will reduce the reliance/congestion on the ED?

1 Initiator: Manabu Koshimura Participants: Margreth Tolson, Manabu Koshimura, Corisande Percival-Smith, Norma Roberts, David Thompson, Zarina Sajoo, Teresa McCausland, Judith Berg, Geoff Pross Discussion Key Points:

Promotion/communication

There is an assumption that seniors have families but many are isolated o Educating care givers about community resources

Discharge planning – improved community resource information in ED Prevention: how do we work together to produce healthy outcomes so that seniors don’t need to access the ED? Creating networks/links between service organizations

o Bring organizations together for information sharing o VCH should be gong out into the community and meeting w/ partners o ACT Now BC

Accessed family doctors to distribute community information o How do we encourage VCH to help emphasize the importance of this

info in the office? Breaking barriers / tensions between organizations

o Prioritizing funding on building community partnerships Integrating health information / education into community events / projects that are not specifically health focused, e.g., Thrift Shop Working w/ school boards / youth centres to encourage multi-generational learning

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Bring health information / facilities to “non-health care” facilities to reach out to people not necessarily accessing hospitals / health centres

o .e.g., events, seniors centres, libraries

Educating VCH staff on community outreach methods and methods on developing partnership

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the hospital?

TOPIC: How do we ensure timely check

2in with patient after leaving hospital to make sure they are progressing? Initiator: Myrna Leishman Participants: Teresa Marconato, Richard Eschelmuller, Allison Cormack, Rick Linger, Anne Sutherland Boal, Leonard Bob, Belinda Boyd Discussion Key Points:

• Enhanced home care support (e.g. Respiratory Therapist, Physio Therapist, Speech / Language Therapist) to provide services to mitigate initial ED visits and reduce follow-up visits

• Training and support for care givers to provide care/therapy to patient to augment care and improve outcomes

• Health line services BC – post discharge component to follow up with patients following discharge

• Phone call is a connection that says someone cares • What if no phone number – is there/could there be a personal follow up • “Call a friend” – community based program that connects with seniors to

keep in touch and ensure they are ok – reintegrating • partnership agreements with community based entities to facilitate

information sharing • family involvement discharge plan should involve family/caregiver –

declaration of who if “family” • enhancing patient history collection to include family / caregiver info.,

associations to community • volunteer involvement to support discharge transition • equip patients with medication, equipment etc. to support their follow up care • issues related to discharge:

o change in physical strength, reduction in cognitive • service to provide medications to discharged patients – set up before

discharge • what are your activities? Who are you? The whole picture of the person

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the hospital? __________________________________________________________________

3TOPIC: Aboriginal Peoples streaming through system and discharge planning Initiator: Pat Turner Participants: Linda Schwartz, Diana Day, Jan McElhaney, Duncan Campbell Discussion Key Points:

• Aboriginal people coming into Lower Mainland Hospitals • Many are ESL – residential school background make then wary of

government buildings • Away from own culture and way of doing things and away from family • Info coming back to the local area is very poor • Medical info • Reason for admission • No discharge plan • OT resources no OT/PT resources in place for 3months • Care not explained even if family is there, patient and family too scared to

ask questions • Communication needs to be 2 way street currently 1 way • Program at VCH –help patient to navigate through the system – patient

navigator • Work with VCH employees to talk to health care professionals so they know

how to communicate • Addressing stereotypes start – starts as soon as you get to the Lower

Mainland • Significant barriers to building capacity in communities • Need shared care plans • Access to resources –meds, equipment • Staff in lower Mainland needs to know what services are available AND

contact local service providers to ensure in place

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• Need to educate the whole system rather than specialized services • “Why should I get that for you; you don’t pay taxes” • Challenge of people who don’t have I.D. –no one should be turned away • Cultural barriers are HUGE • Aboriginal communities needs to be advocates for themselves • Identifying aboriginal people coming into ED get info on them

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the hospital? __________________________________________________________________

TOPIC: Understanding and accepting my medical diagnosis

4 Initiator: Louise Donald Participants: Shannon Berg, Leslie Sam, Ann Mackie, Anna Glaze, Anne Sutherland Boal, Sue Davis, Nancy Breton, Nick Chopra Discussion Key Points:

• Understanding the physical changes that have happened … then they may be better able to follow the care plan.

• How do we help them move to acceptance? • Focus on the principles of age-appropriate health literacy • Health literacy principles in action

o Do they REALLY understand? • Potential of involving the family in the discussion so that they too can hear /

understand. • Spend more time to assess if they UNDERSTAND • Patient may have the BEST understanding of what has happened to them

… but we don’t tap into that knowledge… it needs to be more than just a medical diagnosis. Needs to be a 2-way conversation

• Tap into peoples emotional responses as part of their care. • Need to feel comfortable in order to “get there” … such as just knowing how

to get around in the hospital!! • Take on a position of “coaching” rather than just telling…

o Staff need to learn how to ask questions… • “Meds” question: should include all of the things that you are taking to

modify your bodily functions… eg. metamusil. Staff forget to ask and patients don’t think to mention.

• Transitions: lose the “links” as you move through the hospital …eg. ED staff TO ward…. Or GP/ hospitalist… often there is a real disconnect in the information.

o This is again why families are so important as they offer the linkage.

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• Electronic health record: or being able to tap into a persons history if they cannot tell it themselves.

• Language barrier … need to be able to CHECK IT! • Illiterate … need to be able to access in other ways • “so what does this mean for the future” • Something to ground them! • Write down the info so that they can refer to it later… esp. if family

members weren’t part of the conversation at the start… allows them to understand what went on

• Need 2 way communication: we are responsible for both sides of the coin! o English speaking staff speaking with non- Eng. Speaking Client o Staff whose accent is more difficult to understand to client who

speaks only Canadian accented English • Need to ensure that staff are paying attention to their communication • Need to be attentive to clients “emotional fitness” when they get

discharged… it impacts their ability to understand and implement • Conflicting messages from different HC providers • What about “younger seniors” … those who have support at home – but

don’t have the knowledge or skill to care give at home. • Looking at continuity of care – how do we provide support (different

support) as their condition changes • Ongoing “coaching” that help keep them out of hospital • Conflicting messages. eg. in ED ‘stay still” vs. ion the ward suddenly told

“get up. Move about” • “facilitator guides”… one for staff and one for families

o A list of questions o Checklist of information you have told them… including the

description and background info… • Feeling very vulnerable … need to feel a sense of comfort and confidence in

order to follow their plan. • Really need to UNDERSTAND pain medication process and how to take

effectively. o Need simple education available… that includes a description of why

and how it works • Watch out for clients taking medications that hide symptoms …

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the hospital? __________________________________________________________________

TOPIC: How do we ensure good outcomes for people who can’t 5speak for themselves Initiator: Heather Manson Participants: De Whalen, Caleb Lee, Hatem Ela-Alim, Roberta Tottle, Linda Schwartz, Sheila Pither, Wilma Hallam, Debbie Nider, Ann Mackie, Farahnaz Heidarpour, Lynda McCloy Discussion Key Points: Concern: affects how medical staff communicate with these people

• Medical staff don’t feel they fully understand patients’ history and who the person being treated really is

• Respect – an underlying issue • Need to be shown regardless of whether people can speak. Eg: immigrants

who cannot speak English • Have an informal person support patient, a “navigator”, family member • Translation services difficult to access – not always timely • Seniors need medical staff to slow down to explain things better and so they

can have the time with the senior patient • Seniors in adult daycare have good histories etc. but their transition into

hospital sometimes loses this info. • Create a database (and post it) to identify other languages staff can speak. • Need a system in place for quick health care translation • Could be part of hospital hiring policy • Could add “1st language” to health care card / health record • Link in with multicultural organization to identify people with other language • BC Nurse Line – multi lingual • There is a central registry to enable emergency to contact official rep. for

seniors • Education needed • “Shared care Plan” available on website

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• Continuity of care from emergency – challenges: o no continuity of interpretation of chart (i.e.: receiving different

information from the same chart • Who is the information source? • Need to support families and friends as advocates • Attitudes of some staff need to be overcome – not appropriate for seniors • Need better 2-way flow of communication from patient to caregiver and back • Ill people don’t absorb information under stress • Make existing systems better known • Personal health information record to be carried by everyone. And to

include meds, language, age, current conditions, etc. (several are available in the community … review and select one … then promote!!!)

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the hospital? __________________________________________________________________

TOPIC: Elder Facilities/Services in the Central Coast 6 Initiator: Linda Day Participants: De Whalen, Linda Schwartz, Peter Vlahos, Judith Berg Discussion Key Points:

• Actively engage volunteer and service groups, for example, Rotary – the potential is untapped and unlimited.

• Look at the potential of adapting existing infrastructure to meet some of the capital requirements in rural and remote communities. Examples include Land that can be donated, and similarly old buildings and structures that can be retrofitted – a specific example could be some of the structures (Federal) that exist in and around the lighthouse in Bella Bella.

• Investigate alternative operations frameworks. For example, ‘Elder Care Hubs,’ ‘Rural Seniors Centers of Excellence.

• Include ‘determinant of health’ streams in long term planning. This relates to local capacity building, housing, enhanced education possibilities in the sciences (chemistry, biology, math, physics) so that more young people will have the opportunity to flourish in a chosen health service delivery related field. Incorporate a strong youth volunteer program into this education matrix.

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the hospital? __________________________________________________________________

7TOPIC: Community reintegration: Preparing the caregiver Initiator: Mel Clark Participants: Barbara Greenlaw, Teresa McCausland, Farahnaz Heidarpour, Louise Donald, Myrna Leishman, David Thompson, Linda Schwartz, Heather Manson, Jan McElhaney, Nancy Breton, Nick Chopra, Corisande Percival-Smith, Alison Cormack, Debbie Nider Discussion Key Points:

• Immediate discharge planning • Caregiver should be present at discharge planning meetings • Caregivers may not know what questions to ask. There is an assumption

that caregivers know what to do • How do you develop skills/strengths for caregivers • Consider abilities of caregivers (e.g. age, strength, work, etc.) • Caregiver’s list of tasks needs to be properly explained and customized to

individual situations • Acknowledgement is sometimes not enough to understand a task. Practical

experience is important • What support is out there for caregivers

o Nurse line o Support services info. should be part of the discharge planning

(phone numbers) o Follow up calls/meeting are integral for caregiver support o Linking caregivers together to support each other to share

experiences • Understanding the cultural differences in care-giving (e.g. traditional

methods: is it beneficial? Is it adverse?) • Ensuring that the caregivers can communicate appropriately with the people

that they are caring for (e.g. language, accents, hearing ability) • Having a conversation with caregiver instead of just going through the

checklist

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• Understanding the physical barriers at the home o Do you live on a hill? o Wheelchair access: ramps/size of doorways? o Bathing facilities: shower/bath?

• There should be a program that assists caregivers with renovations to their homes

• Also educating the community about making your home accessible for the future

• Also ensuring new development is accessible • Rather than going through a discharge checklist, caregivers should be

encouraged to ask questions. Make caregiver part of the process of creating the discharge plan

• Sensitivity to caregiver health (e.g. burnout • Transitions are not smooth. Different departments / agencies dealing with

different aspects of discharge. This is stressful/confusing for patient and caregiver

• Health authority needs to focus on the caregiver too, not just the patient

Additional comment brought to typist: • Privacy legislation can interfere with the hospital’s involvement of caregivers

with discharge planning (legislation says the hospital is not allowed to give discharge planning information to community services, which support the caregiver and patient. The hospital can share info. if there is a release signed by the patient, but this is not being done. The hospital makes a referral to the community service, but patients/caregivers are not following up. Could community services participate in the discharge planning? This is what used to happen before the legislation came in).

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the hospital? __________________________________________________________________

TOPIC: Process / flow chart through an episode of care

8 Initiator: Hatem Ela-Alim Participants: Jane De Lemos, Sheila Pither, Shannon Berg Discussion Key Points:

• Two goals in ED o what is wrong o meet needs – where do they need to go

• If admitted will be asked same thing more than once (for different reasons) • Might be written in more than 1 place or not written at all • Maybe how it is asked – “ You may have been asked this before but I just

need to clarify….:” Asked in a respectful way • Nurses & doctors may not be the best communicators because we take the

language for granted; make assumptions that patient understands or already knows

• May use different language • What about a booklet that tells what to expect; what questions a

patient/family member should ask and if a patient can’t read it what about a family member

• Language barrier: preferred language of communication should be a first question early on. Also notes on whether patient has hearing difficulty. On Medicare card along with demographic info

• Seniors may not hear what you’re saying and may not acknowledge that. Use devices to ensure they can hear or have heard.

• A question should be asked, “how would you like to be treated “ • Personal preference – those who want all the details & want to understand

can sometimes be treated like they are a nuisance • Assumptions by health professionals about what the role of a patient/family

should be. We need to ensure we don’t make assumptions • Health care is question/answer top down communication unless a

patient/family is persistent

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• Health care professional can ask – “How much information do you want?” ” Who would you like to be included?”

• A face sheet with basic info, demographics, etc. • Example – took BP asked what it was & they said “Oh, it’s pretty high” but

didn’t say what it was • Frustration when patient who have info are not listened to or not followed

up. Eg took ½ a tablet • Information provided on discharge • Don’t understand lines of authority e.g. between nursing and physicians so

don’t know who to ask, who makes decisions, who gets involved. Can I say “I would like a physio consult?”

• Asked for audiologists consult & unit said couldn’t happen but when they phoned directly to Audiology the audiologist came up.

• What rights do you have? Customer service • knowing what you need to go home, “Ticket to home” • We say we need to meet patient needs but don’t ask them what they need. • Would help staff and patients/ families to state what the process is to get

referrals or get information etc. Who do you ask? How long will it take? • Patient doesn’t know what to expect. Lost opportunity if processes aren’t

made clear to patients to ensure better care and for efficiency sake.

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the hospital? __________________________________________________________________

9TOPIC: Family help in the hospital Initiator: Rick Linger Participants:

• Duncan; Zarina; Rick Linger; Anna Glaze; Roberta Tottle; Richard Eschelmuller; Anne Sutherland Boal; Caleb Lee

Discussion Key Points:

• Different hospitals have different rules about what family is allowed to do • Families helping feeding: HCP’s scared about litigation / safety • Assessing families willingness to help • Some HPC’s “force” patients to “help them” = causing risk • Cultural practices may interfere with others safety eg.= smudging • Facilities that allow cooking of traditional/ cultural foods … ie kitchens • Allowing families to bring own food • Not allowing families to bring food into hospital • Nursing homes don’t allow patients to “cook” nursing homes … not willing to

take patients to specialists for an appointment • Encouraging families that aren’t willing: timelines (give enough time) • Paternalism of the health care providers • Encouraging family advocacy ( as long as medically indicated) • LTC: degree of intervention on end of life • Dying at home VS in hospital … giving family resources • Overcapacity of acute care • Giving families resources in dealing with end of life care (particularly when

in last stage of life) • How to encourage families that are not willing to visit dying families…

putting HCP in the middle • Protecting patient from family (emotional financial abuse) • Advance care planning … power to attorney/ wishes • Encouraging end of life decision making early on… with families but

recognizing changes in decision • Encouraging families to listen about end of life

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• Encourage seniors to talk about dying together, to be more comfortable • Public discourse about dying …

o might be harder to talk to loved ones o neutral area might be easier to talk about

• “summer days” … movie about death and dying • family taking more responsibility to care …

o staying in hospital o expect people to care of families not just request

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the hospital? __________________________________________________________________

TOPIC: How do we make the emergency staff / facilities more Aboriginal friendly to promote access of services? 10 Initiator: Diana Day Participants: Diana Day, Lynda McCloy, Leslie Sam, Anne Sutherland Boal, Wilma Hallam, Leonard Bob, Geoff Pross, Pat Turner Discussion Key Points:

How do we make our ER staff / facilities more Aboriginal Culturally friendly

Aboriginal communities provide public relations to VCH staff o Media and population at large

VCH staff going to community to give orientation to members Training discharge planners on resources available in communities from where patients live, ie., Bella Bella, Mt Currie – rural and remote communities Having VCH staff being open to cultural differences within the First Nations culture – give folks some tools

o Develop tools to work with First Nations people o Some flags developed for staff

What are some of the tools that could be developed? o Background on patients o Educate both community and staff on what’s available on each end

3 questions i.e., pediatrics o What has made you sick? o What will make you well? o Who do you what us to communicate with?

Add: Is there something about your belief, culture or family, that I need to know to make your stay better?

o Staff to be more ‘plain language’ when giving directions on needs, i.e., ‘mid stream urine sample’

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o Explaining things in more detail and giving more time for questions Language barrier – cultural sensitivity / safety smudging

Dispelling mistrust of hospitals in First Nations communities o Starting / including school age children

Have VCH Aboriginal Patient Navigator program aware of these issues and part of the training

o Be the link to the emergency / hospital How do we make the people trust the staff – when others may have had a bad experience with a staff?

o Navigator becomes and ombudsman o Confidential complaints reported

VCH has an Aboriginal toll free line o Help line could be a complaint or advocacy o Report bad experiences for follow up o Some Elders trust priests more than doctor and need to include them

in the care plan Having pamphlets on how to complain effectively Role for Aboriginal Patient Navigator

o First Nation patient may not complain in writing o Verbal / anonymous, confidential

Education programs for emergency staff o Technology words brought / explained so people understand o Taking time to ensure it is understood

Please include this material to the Learning Session in November “Patients as Partners”!!

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the hospital? __________________________________________________________________

TOPIC: While in ED, practical issue of toileting the older patient 11 Initiator: Norma Roberts Participants: Geoff Pross, Anne Sutherland Boal, Teresa McCausland, Heather Manson Discussion Key Points:

• Large source of anxiety for patients and also family members • Need for proactive managing –questioning the patient when they arrive to

ED about toileting needs • To clarify the role of the family or support person in the toileting process to

confirm if family can help the patient to toilet • “Positive Toileting” normalize the need

o Timeliness o Privacy o Safety- avoiding falls

• Signage or posters to help the patient navigate (find their way) to the toilet or phone or to show choices (visually) regarding toileting options for example, bedpan, commode or walk to toilet (to be applicable to all patients regardless of language)

• Fear of catheterization if the person is incontinent or has an “accident”

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the hospital? __________________________________________________________________

TOPIC: How to assist / facilitate patients and family members advocating for the care they want / need? 12 Initiator: Shannon Berg Participants: Wilma Hallam, Roberta Tottle, Sheila Pither, Linda Schwartz, Louise Donald, Anne Zarina, Mel Clark, Myrna Leishman, Nancy Breton, Debbie Nider, Barbara Greenlaw, De Whalen, Caleb Lee, Manabu Koshimura, Lynda McCloy, Corisande Percifal-Smith Discussion Key Points:

• Mindset in health professional that families can be advocates • Important for families to “take on” the responsibility but need the information

and support to do so • Be welcomed • Have a contact person on the ward • Families are phoned by staff and asked to escort the patient to an

appointment, but family may not be able / interested in escorting / assisting, and tell staff to “get an escort” - what do the staff do then?

• One the one hand, staff are trying to involve family, but on the other hand, maybe family need to be involved differently? Or earlier? (not just escort)

• Maybe start with learning how to advocate for ourselves • Engagement of doctor and patient in goals of care / advance health

planning happened because she advocated for herself • Family friendly policies in workplace. Negotiate family friendly policies. (e.g.

through unions) • Whoever admits: to provide patient / family expectations: what could be

done and what facilities need to do • “There may be times when we need family to help; is there someone we can

call?” Then starting from realistic expectations

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• Who is an advocate? • Who can be part of care planning? • If there isn’t anyone, staff know they need to problem-solve • Then staff need to continuously involve that person, not just at beginning • Pain: examples of advocating for people with short term memory gaps • Need tools to be able to assist • ‘Advocate’ is a bad word: instead use: Helper? Assistant? Friend? Support

person? • Differences of opinion between patients and family members, and

differences between family members • Physician who listed all the options to all the family members • Advanced directives / living wills – everyone should have one • Information about new legislation to augment representation agreement,

easier. Will not require a lawyer. • Wise for person who made it to have copy and also a family member to

have a copy • Have to have the discussion when you create a living will. Not just the

paper important – the discussion is important • Everyone to have a health booklet with medications, care plan, and health

directives, including the contact person • Opportunity for VCH to partner with the right groups

o CHAC o Seniors centres o Faith groups o Old age pensioners organizations o COSCO (Council of Senior Citizens of BC) o Zoomers (was Association of Retired People)

• Film Festival movie “Summer Days” about death and dying – good resource to introduce conversation

• Health professions have to ask questions about how patient was, and value the answers

o What caused this illness? o What do you think will make you better? o What else do I need to know to help you?

• Key questions that professionals always ask even when busy • Story, re: pain – “out of 10, how bad is your pain?” She said “10” thinking

“10” was good • ESL – if there are 2 questions, will answer the second • As legislation comes out, VCH could take a lead in having discussion with

community about how to make it work: new legislation as an opportunity • Like the old vial of life: medic-alert bracelet that says “No DNR” (but needs a

doctor – which is very hierarchical) • Need to find ways to begin the conversations in families • Introduce conversations • VCH could provide leadership in community

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• Perhaps hold an open forum. Neutral setting with stranger is easier for difficult emotional topics.

• Lots of booklets out there – e.g. a funeral home had a booklet, an excellent resource for care-planning regarding death and dying. This was a great tool for family member of patient. Get hold of already completed materials so we don’t have to re-create these resources.

• Timing is everything. When media picks up on new legislation, have arrangements for education / forum ready

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the hospital?

13TOPIC: End of Life Palliative Care: Aboriginal Cultural Needs Initiator: Linda Day Participants: Farahnaz Heidarpour, Anne Harvey, Pat Turner, Linda McCloy, David Thompson, Geoff Pross, Leslie Sam, Diana Day, Peter Vlahos Discussion Key Points:

Protocol for different cultures

# of people in waiting room – hospital emergency The community needs homes so they can be in community at end of life Support for family and communities when death occurs Grieving supports Closest community support w/ Pemberton but there is racism Being able to drum, sing, smudge for people Staff education around cultural practices on end of life care – food, seafood, deer Foods being brought in Staff being sensitive to patients food needs at end of life Require fundraising for Aboriginal people attend end of life for elders Hospice availability or palliative care availability

o People wanting to go home for end of life, die at home o Staff / doctors being insensitive to patients, i.e., Campbell River to BB

the doctor said “Well, don’t die here” First Nations communities need support to have palliative care homes in their communities, i.e., BB needs place for care building so people can care for members

o We can only send 1 person to travel with patient at end of life o Elders coming back to community because they ant to finish time on

earth at home with family, but sent out always to die Leveraging existing resources for end of life care How to work with those kids who are grieving at loss of Elders dying – support for those who have terminally ill relations in community Educating schools/community staff on who may be grieving

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More grief/grieving resources for families

o Grief counselors o For all other losses and end of life o Some communities have priests who are trusted

Help to navigate trough the system – cultural beliefs around death and dying Help to influence VCH culture to acknowledge different ways/practices in grieving and feeling safe – sacred space in VCH sites not just chapel but open to smudging, singing, praying Having VCH designed space for grief work with patients Allow large families to enter rooms as people need to say goodbye to family members (have larger waiting rooms) Flexible space available to allow community to come to visit pay respects to the person in hospital

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the hospital? __________________________________________________________________

TOPIC: Medications: how can we help you get the most out of them and take them safely? 14 Initiator: Jane De Lemos Participants:

• Jan McElhaney; Anna Glaze; Alison Cormack; Nick Chopra; Hatem Ela-Alim Discussion Key Points:

• Meds are designed to make you better… to decrease your symptoms… to decrease your adverse effects

• Choosing the correct medication for management • Getting 2 different prescriptions from 2 different MDs

o resolution supposed to occur via the pharmacist/ pharmamed o discretion between pharmanet and what patient is actually taking

• Assuming that Pharmanet print out is actually what the patient is taking • Blisterpacking takes care of that somewhat • Overmedication…. Medications to counter the side-effects • Patient NOT willing to admit what they are actually taking… want to please

the MD • Helpful to let patients know that if they don’t feel better after taking

medications for a period of time, to go back to pharmacist • Need to give small amounts of info so patient is more comfortable asking

questions. o Still make time for more conversation o Don’t seem to be in a hurry …

• HCPs stuck in how much information to give patients • Self medication with OTC • Medication reconciliation and discharge summary • Gaps in treatment of chronic diseases… eg. Osteoporosis … meds to take

that decrease the risk of future falls…low % of people should be on medications actually are

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• Should pharmacists have more active role in chronic disease management • role of GPs in hospital with starting and stopping

o ownership … who owns the “case” o with patient but give opportunity to educate

• Giving information to patient and info to GP should be done instead of starting meds for chronic illness in hospital?

• Get pharmacist to review the meds and make suggestions to GPs • Issue with follow up … length of time … some diseases not an issue • Follow up with patients after D/C (RH) all points that are discussed (esp if

over 70yrs) • In hospital education to families (or informed caregivers) regarding

medications … issues with confidentiality • Manitoba Institute for patient safety has designed a Medication Safety Card

that patients carry with them. It is a thorough, simple and “lay term” card, listing all medications, the amounts, purpose, referring physician, etc., Very practical, and health care provider can use this as teaching tool with patient. We don’t need to create this from scratch: MIPS has this on their website for anyone to use. (Linda Dempster of Quality and Safety has seen and likes resource).

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the hospital? __________________________________________________________________

TOPIC: Support from VCH to build an Elder Care Centre 15 Initiator: Leonard Bob Participants: Judith Berg, Duncan Campbell, Richard Eschelmuller, Rick Linger Discussion Key Points:

• Partnerships with VCH and ILB (Independent Living) Health Canada, Indian and Northern Affairs Canada – began 4 years ago

• Funding ($15K) was given for feasibility study from VCH , ILB & INAC • Almost there 98% there to start the building phase • Planning collapsed; put on hold • Recently learned that INAC had a pilot project for two 10 ILB bed homes.

Only 2 proposals in BC were being considered • Completed a proposal and business plan for TREASURY Board (Ottawa) in

mid July 2008 • Still awaiting word on submission and if will be approved • Federal elections are interfering with process • No indication as yet if proposal will be one of two slated for BC • Coastal COO was consulted on need for 10 complex care beds; explained

project that had been propose to Ottawa to MA and provided a copy of business plan and proposal

• MLA’s and MP’s were also consulted • we wait in hope

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6. Priority List

Priority # Topic # Topic

23 7 Community reintegration: Preparing the caregiver

22 12 How to assist / facilitate patients and family members advocating for the care they want / need?

20 1 What effective community partnerships will reduce the reliance/congestion on the ED?

18 4 Understanding and accepting my medical diagnosis

17 5 How do we ensure good care / good outcomes for people who can’t speak for themselves

14 8 Process / flow chart through an episode of care

13 14 Medications: how can we help you get the most out of them and take them safely?

13 9 Family help in the hospital

12 10. How do we make the emergency staff / facilities more Aboriginal friendly to promote access of services?

12 3 Aboriginal Peoples streaming through system and discharge planning

10 2 How do we ensure timely check in with patient after leaving hospital to make sure they are progressing?

8 13 End of Life Palliative Care: Aboriginal Cultural Needs 6 11 While in ED, practical issue of toileting the older patient 4 15 Support from VCH to build an Elder Care Centre 1 6 Elder Facilities/Services in the Central Coast

Additional thoughts of the day:

• Combine the aboriginal health numbers • I was thinking “what is this about?” no agenda’s

o Very interesting o Great listening o Learned a lot o Would this work with politics?

• I now understand my parents issues so much better • Very helpful on a personal level • Great information in the breakout groups! • Excellent tangible things to work on • I have shifted my personal perspectives • Very interesting learning • Lots of info to pass onto other ‘tables’

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• Lots of personal stories shared o Gave a strong perspective on the ways it impacts individual lives

• Thankful for CE in this organization – and CHAC’s inside the organization – great significance

• Able to come to meet CHAC’s • Really interesting experience • Appreciated it was a circle • Dialogue helped me better understand my own situation • Glad to share with everyone

7. Evaluation There were 30 responses submitted.

A. Describe your level of satisfaction in regards to this meeting:

Low Acceptable Good High

30%

70%

B. Were the goals and objectives of this meeting met?

Yes Partially No

86%

14%

Comments:

• A great experiment…..gone right! • Idea’s were falling from the sky like apples from a tree. • Learned lots of useful tips for improving own family care. • I appreciated the framework of the meeting, it allowed for opportunities

of participation and being new, I thought I had nothing to offer and I discovered I did.

• I was a bit skeptical about the open space at the beginning of this day but it came together nicely.

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• New different process for me • Extremely well organized • Full participation on my part • Excellent food • Hard work • Senior’s care is at my heart – it’s what I do – my work • I learned some new things, eg: “living will”, etc. • Able to vent my frustration with families, eg: escorting their loved ones

for Specialist appointments, etc. • I really appreciated signs that directed us to the “gym” – good work. • Thanks! • We saw a lot of similar experiences bring good solutions and problem

solving. • We received a lot of excellent suggestions to assist seniors in several

capacities in our communities. • I would like to see what kind of follow ups will be in place after this

meeting. • The meeting was very well organized and run, and, as advertized, it was

fun. • I learned a lot and enjoyed the discussions – there is much to be done. • The open space concept was interesting and I think effective. I felt that

participants felt more comfortable therefore more forthcoming with ideas. • Very well organized – nice that we were able to set agenda items that

were directly of interest to the group. • Great choice of food. • Well done – thanks. • My first chance to meet with other CHAC groups and see what other

groups (concerns) and solutions that have been successful or not. Take away other ideas for our CHAC to see if we can implement.

• Very lively and informative day, and very interesting start with the circles. • I liked the Open Space facilitation tool. Very well done, got a lot of work

done. Kudos to the facilitator Hilary! • Open concept is very positive strategy and worked well for this forum. • Good participation from audience. • Nice mix of ideas. • Having separate seminar / meeting rooms for small groups was a huge

bonus. • We need to ensure that the SET is committed to continue with the Joint

CHAC events at minimum twice a year (in Sep 07/Jun 08 there was only one).

• I am looking forward to the next joint event in Apr – Jun ’09. • A very creative, dynamic approach. • Lots of energy and committed participation. • I really enjoyed the open space technology. I didn’t think I would feel

qualified to contribute but very quickly felt comfortable and valuable.

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• Thank you! Awesome day. • The “open space” idea, which actually has a lot of underlying structure,

was very useful to pull “out of the box” thinking while providing safe structure.

• Question was focused enough that we could attempt to tackle it, but broad enough to be inclusive.

• Very productive – our TSC initiative had not considered these barriers to implementation of guidelines even though we know that they are challenges to care delivery. Lots of great ideas.

• Did some groups / sessions work on the central question sufficiently. • Some of these ideas and proposal could be blended before put to vote. • I expect to discuss how to engage community in implementing the

“Transforming Senior Care Project”, but we did not talk too much based on this project. However, I enjoyed the overall discussion and format.

• The right mix of people with problem solving skills & experience. • Format worked amazingly well considering the number of people. • My first JCHAC meeting &I it was great to meet the other attendees. • More to come with wider community – ie: educational forums, etc.

transforming seniors care - vch

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