transitional stage – palliative care poc light...
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Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access
Centres/Association des Centres d’accès aux soins communautaires de l’Ontario, 2012. All rights reserved. Unauthorized
distribution and duplication strictly prohibited.
Page 1 of 17
Client Details
Name
Client ID
Date Pathway Activated
Date Pathway
Discontinued
Reason for
Stoppage
Drop-Down or radio button
o Moved to a different pathway
o List reason: ____________
o New pathway: ___________
o Admitted to Hospital
o Admitted to PCU
o Admitted to Hospice
o No longer palliative
o Deceased
o Other ______________________
Pathway Identification
Pathway Name Transitional Stage – Palliative Care
Presenting Issue or
Condition Defined
Based on client’s functional performance as defined by the Palliative
Performance Scale (PPS). Transitional stage for palliative clients is defined
as clients with a PPS of 60-40 and or by the clinicians’ assessment upon
review of additional clinical indicators and or tools.
Exclusion Criteria Clients <18 years-old
Coding Requirements
(e.g. specific local referral
codes)
N/A
Overall Pathway
Outcome
Elements in place to support the client and caregivers throughout the
palliative care journey.
Pathway Evaluation
Date Created May 28, 2012
Date Reviewed
(Subject Matter Experts)
Subject Matter Experts
Date Approved
Frequency of Review TBD
Next Review Date
What triggers a special
condition review of
pathway
TBD
Version [Created from 0v12 – October 29, 2012]
POC LIGHT VERSION 0v02-20121101
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 2 of 17
Interval
Best Practice Guideline
Outcome Reporting Outcome
Evaluation
Barriers to Outcome
Achievement
Follow-up Actions
0 – 7 Days Cancer Care Ontario:
Palliative Care
Collaborative Care Plan
– Transitional Stage
Canadian Hospice
Palliative Care
Association: A Model to
Guide Hospice Palliative
Care
o Comprehensive,
holistic inter-
professional clinical
assessment or
reassessment
completed
Date: __________
o SPO report
Date: ________
o Outcome not
met
Date: __________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:______________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
0 – 7 Days Cancer Care Ontario:
Palliative Care
Collaborative Care Plan
– Transitional Stage
o Clinical care plan
which incorporates
client values and
goals initiated/
updated
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 3 of 17
Date: __________
Date: __________
Date: __________
Date:_____________
Date:_____________
0 – 7 Days o Plan for 24/7 access
and responsiveness
initiated/updated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date: __________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:______________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
0 – 7 Days o Risk assessment or
reassessment
completed and
support in place to
ensure only
appropriate
hospitalization or ED
visits
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Premature
discharge from
hospital
o Other
____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 4 of 17
Date: _______
Date: __________
Date: __________
Date:_____________
Date:_____________
0 – 7 Days Cancer Care Ontario:
Edmonton Symptom
Assessment System –
Description
Cancer Care Ontario:
Edmonton Symptom
Assessment System -
Tool
o ESAS administered
as indicated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date: __________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
0 – 7 Days Cancer Care Ontario:
Victoria Hospice
Palliative Performance
Scale - Description
Cancer Care Ontario:
Victoria Hospice
Palliative Performance
Scale - Tool
o PPS administered at
each visit
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 5 of 17
Date: __________ Date: __________ Date: __________ Date:_____________ Date:_____________
0 – 14 Days o CCAC client care
plan which
incorporates client
values and goals
initiated/updated
Date: __________
o CC
documentation
Date: ________
o Outcome not
met
Date: __________
o Resource barriers
o Client/family
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:______________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
0 – 14 Days o Most responsible
physician and/or
support plan
identified/updated
Date:_____________
o CC
documentation
Date: _________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o CCAC
o Physician
availability
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address
resource barriers
o Advocacy
o Explore
alternative
supports
o Contact client /
caregiver
o Other
______________
Date:_____________
21 – 28 Days o Common access o SPO report o Outcome not o Resource barriers o System
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 6 of 17
established/updated
to relevant client,
care and health-
related information
Date: __________
Date: __________
met
Date: __________
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
21 – 28 Days Canadian Hospice
Palliative Care
Association: Speak Up –
Advance Care Planning
o Advance Care
Planning
initiated/reviewed
with client and
documentation
updated
Date:_____________
o SPO report
Date:___________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
21 – 28 Days o Plan for expected
death
initiated/updated
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o System
navigation to
address resource
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 7 of 17
Date:_____________
Date:___________
Date:__________
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
21 – 28 Days o Client preferred
place of death is
determined
Date:___________
o SPO report
Date:___________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
21 – 28 Days
o Life completion
activities reviewed
with client and
documentation
updated
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o System
navigation to
address resource
barriers
o Contact client /
caregiver
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 8 of 17
Date:___________
Date:___________
Date:__________
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o Other
______________
Date:_____________
21 – 28 Days o Preparation for
bereavement after-
care needs initiated
Date:___________
o SPO report
Date:___________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
21 – 29 Days o Common access
established/updated
to relevant client,
care and health-
related information
o CC
documentation
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 9 of 17
Date: __________
Date: __________
Date: __________
o Client declined
o Other
____________
Date:_____________
Date:_____________
21 – 29 Days o Funding resources
identified/updated
and referrals
complete
Date: __________
o CC
documentation
Date: __________
o Outcome not
met
Date: __________
o Resource barriers
o Client/family
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
21 – 29 Days o Needs are being met
by community
supports/resources
o CC
documentation
o Outcome not
met
o Resource barriers
o Client/family
o Community
support or
resource
o Unavailable
o Waitlisted
o CCAC
o System
Client readiness
o Psychological
o Physiological
o System
navigation to
address resource
barriers
o Advocacy
o Explore
alternative
supports
o Contact client /
caregiver
o Other
______________
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 10 of 17
Date:_____________
Date:__________
Date:__________
Client declined
Other____________
Date:_________
Date:_________
21 – 29 Days Canadian Hospice
Palliative Care
Association: Speak Up –
Advance Care Planning
o Advance Care
Planning
initiated/reviewed
with client and
documentation
updated
Date:_____________
o CC
documentation
Date:___________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
Q28 Days Cancer Care Ontario:
Palliative Care
Collaborative Care Plan
– Transitional Stage
o Clinical care plan
which incorporates
client values and
goals updated
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 11 of 17
Date: __________ Date: __________ Date: __________ Date:_____________ Date:_____________
Q28 Days o Plan for 24/7 access
and responsiveness
updated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date: __________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:______________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
Q28 Days o Risk assessment
completed and
support in place to
ensure only
appropriate
hospitalization or ED
visits
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Premature
discharge from
hospital
o Other
____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 12 of 17
Date: _______
Date: __________
Date: __________
Date:_____________
Date:_____________
Q28 Days Cancer Care Ontario:
Edmonton Symptom
Assessment System –
Description
Cancer Care Ontario:
Edmonton Symptom
Assessment System -
Tool
o ESAS administered
as indicated
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date: __________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
Q28 Days Cancer Care Ontario:
Victoria Hospice
Palliative Performance
Scale - Description
Cancer Care Ontario:
Victoria Hospice
Palliative Performance
Scale - Tool
o PPS administered at
each visit
Date: __________
o SPO report
Date: __________
o Outcome not
met
Date: __________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
Q28 Days Canadian Hospice o Advance Care o SPO report o Outcome not o Resource barriers o System
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 13 of 17
Palliative Care
Association: Speak Up –
Advance Care Planning
Planning reviewed
with client and
documentation
updated
Date:_____________
Date:___________
met
Date:__________
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
Q28 Days o Plan for expected
death updated
Date:_____________
o SPO report
Date:___________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
Q28 Days
o Client preferred
place of death is
updated
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
navigation to
address resource
barriers
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 14 of 17
Date:___________
Date:___________
Date:__________
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o Contact client /
caregiver
o Other
______________
Date:_____________
Q28 Days
o Life completion
activities reviewed
with client and
documentation
updated
Date:___________
o SPO report
Date:___________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
Q28 Days o Preparation for
bereavement after-
care needs updated
o SPO report
o Outcome not
met
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o System
navigation to
address resource
barriers
o Contact client /
caregiver
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 15 of 17
Date:___________
Date:___________
Date:__________
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o Other
______________
Date:_____________
Q28 Days Canadian Hospice
Palliative Care
Association: Speak Up –
Advance Care Planning
o Advance Care
Planning reviewed
with client and
documentation
updated
Date:_____________
o CC
documentation
Date:___________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o SPO
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Date:_____________
Q56 Days
o CCAC client care
plan which
incorporates client
values and goals
updated
o CC
documentation
o Outcome not
met
o Resource barriers
o Client/family
o CCAC
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
o System
navigation to
address resource
barriers
o Contact client /
caregiver
o Other
______________
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 16 of 17
Date: __________
Date: ________
Date: __________
____________
Date:______________
Date:_____________
Q56 Days
o Most responsible
physician and/or
support plan
updated
Date:_____________
o CC
documentation
Date: _________
o Outcome not
met
Date:__________
o Resource barriers
o Client/family
o CCAC
o Physician
availability
o System
o Client readiness
o Psychological
o Physiological
o Client declined
o Other
____________
Date:_____________
o System
navigation to
address
resource barriers
o Advocacy
o Explore
alternative
supports
o Contact client /
caregiver
o Other
______________
Date:_____________
Q56 Days
o Needs are being met
by community
supports/resources
o CC
documentation
o Outcome not
met
o Resource barriers
o Client/family
o Community
support or
resource
o Unavailable
o Waitlisted
o CCAC
o System
o Client readiness
o Psychological
o System
navigation to
address resource
barriers
o Advocacy
o Explore
alternative
supports
o Contact client /
caregiver
o Other
Transitional Stage – Palliative Care
POC LIGHT VERSION
POC LIGHT VERSION 0v02-20121101 © Community Care Access Centre/Centre d’accès aux soins communautaires and Ontario Association of Community Care Access Centres/Association des Centres d’accès aux soins
communautaires de l’Ontario, 2012. All rights reserved. Unauthorized distribution and duplication strictly prohibited.
Page 17 of 17
Date:_____________
Date:__________
Date:__________
o Physiological
o Client declined
o Other
____________
Date:_________
______________
Date:_________