“It’s the Right Thing to Do”: Alberta’s province-wide approach to provide palliative care at home

For Alberta Health Services, necessity was most definitely the mother of invention.

Several years ago, home care staff were made aware of a puzzling situation. The family of a patient receiving palliative care at home was calling 911 with medical concerns several times a week – even though there was a palliative care team in place that was regularly visiting and providing care in the home for the patient. To make things even more confusing, neither the home care team nor the family physician were even aware that many of these calls were being made to 911.

Complex care issues or urgent symptoms often leave community clinicians and paramedics no option but to transport clients to hospital during an unanticipated crisis.

Seeing this as an opportunity for improvement, a small team focused on finding a solution at a systems level, bringing all services together – physicians, paramedics, nurses, respiratory therapists, pharmacists, and others – to address the problem by creating something new.

Their efforts resulted in the implementation of a local initiative to support palliative and end-of-life care patients at home in collaboration with home care teams. A few years later, the innovation evolved into the Alberta Health Services Provincial Emergency Medical Services Palliative and End-of-Life Care Assess, Treat and Refer Program, or EMS PEOLC ATR program.

In this unique program, front line paramedics work collaboratively with the client’s primary and palliative care teams, and an online physician, to support clients receiving palliative and end-of-life care in the community who require urgent symptom management – particularly those who wish to remain at home while nearing end-of-life. Unique resources available on the ambulance (medications and oxygen) are used to manage, in the client’s home, the most common palliative and end-of-life symptoms: pain, nausea and shortness of breath.

Collaborative care between paramedics and community teams

Nurse and paramedic collaborate to assess and treat a client in the home with family member

“It makes good sense”

The program was, and is, successful because it simply makes good sense. “It wasn’t about looking for new resources,” says Cheryl Cameron, lead for the EMS PEOLC ATR program with Alberta Health Services. “It was really about looking at practitioners who were already out in the community providing care to the patient, and figuring out how can they work together in a more collaborative manner.”

For the most part, the transition to the new program was smooth. “There was a positive response from patients and families,” explains Charlotte Pooler, a clinician scientist with the palliative and end-of-life care and community programs in Edmonton Zone. “And there was little resistance from community care or EMS staff,” she adds. “They loved it because it was a person-driven solution.”

Initially, some worried that treating patients at home could potentially deplete valuable and scarce EMS resources in the community.

However, it soon became apparent that moving away from the “treat and transport” approach was having the opposite effect – saving time and using resources more appropriately by treating patients right in their home rather than taking them to the hospital emergency department.

As the new model was implemented across the province, many opportunities were provided for education and open communication, and the results of satisfaction surveys were compiled. “After the 3 month pilot in Edmonton, one family member thought it was the greatest thing since sliced bread,” Charlotte says. “It made such a difference to them to receive treatment at home and avoid a hospital visit when it wasn’t necessary.”

Improvements to date have been across the whole spectrum of care. Paramedics are feeling fulfilled as they are now being supported to work to the full scope of practice. Healthcare professionals in the community appreciate the collaboaration and resources. There is more effective communication between healthcare providers and families. Most significantly, because the approach was designed to be aligned with the clients’ wishes and goals of care, patients are reporting improved quality of care and quality of life.

“Now we have options, where we didn’t before,” says Cheryl. “We can treat in place. And we know that’s the right thing to do for patients and families.”

Paramedic providing care to a patient

Paramedic providing care to a patient

Paramedics Providing Palliative Care at Home: Nova Scotia and PEI collaborate for improvement

In Nova Scotia and PEI, a similar program is improving the experience of palliative and end-of-life care for patients and their families.

The Paramedics Providing Palliative Care at Home Program is an inter-provincial implementation of a Clinical Practice Guideline, educational package and electronic access to care plan for paramedics responding to, and supporting, patients receiving palliative and end-of-life care in the community. Paramedics and members of the patient’s care team work together to increase 24/7 access to care in all parts of the provinces, improve the coordination of care, and provide care aligned with the patient’s wishes, goals of care and preferred location of care.

As with the program in Alberta, the Nova Scotia/PEI program was born out of need.

Alix Carter, medical director of research for Emergency Health Services in Nova Scotia, explains: “Families were calling 911 for various reasons – a faster response, unable to reach their care team, etc. Goals of care weren’t clear to paramedics and there was a conflict between what families needed and what paramedic protocols directed,” she says. “We weren’t speaking the same language. There was a huge disconnect between our mutual understanding of what we could and should provide for palliative patients at home.”

Marianne Arab is the provincial manager of psychosocial oncology and palliative/spiritual care for the Nova Scotia Health Authority’s Cancer Care Program. “It was clear that there was a gap in care,” she states, “as there was no 24/7 access to palliative care services across the province.” The solution was equally clear. “Families told us that they could get an ambulance in 10 to 15 minutes, and paramedics were available 24/7. Paramedics were already being called to treat and transport palliative patients, so this initiative was a good fit and helped to bridge the gap.”

Following consultation with healthcare professionals, and patients and their families, the province implemented an innovative program that broadens the scope of emergency medical services by educating and empowering paramedics to provide palliative and end-of-life care at home.

It received an overwhelmingly positive response. “Right from the beginning, people thought it was a great idea,” says Marianne.

Evaluating, educating, improving

Funding from the Canadian Partnership Against Cancer was used to develop the clinical practice guideline, provide education sessions for paramedics and improve access to goals of care. Ongoing evaluation was also part of the plan.

“We did a three-part evaluation,” Alix explains. “Part 1 was with paramedics, before and then 18 months into the project. Part 2 was with patients and families. And in Part 3, we evaluated the initiative from a health systems perspective.” The results of the evaluation were compiled, analyzed and used to make ongoing improvements.

Significant positive outcomes are being seen at many levels. Nova Scotia will soon launch a province-wide policy on expected death at home; there is more dialogue with the RCMP and local police related to changing their response protocol; a clear, accessible process is in place to allow families to identify areas for improvement in the provision of care; and paramedics are content to be working to their full scope of practice for this population.

“We had some great feedback from our EMS professionals on this initiative,” says Alix. “One of them actually said ‘I still remain incredibly proud and humbled by this role we as paramedics are now in. I hope our model can lead to the creation of similar paramedic care models across the country.’”

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These two initiatives have been selected as promising innovations to spread and scale across the country by CFHI’s Open Call for Innovations in Palliative and End-of-Life Care.

November 2017