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Implementing theSerious Illness Care Program into
“non-palliative care” settings
Jessica Simon, Amy Tan, John YouAdvanced Learning in Palliative Medicine
May 24, 2019Calgary, AB
Faculty/Presenter Disclosure
• Faculty: Jessica Simon • Relationships with financial sponsors:
- Grants/Research support: Canadian Institutes of Health Research, Canadian Frailty Network and Alberta Innovates- Speakers Bureau/Honoraria: N/A- Consulting Fees: N/A- Patents: N/A - Other: Physician Consultant Advance Care Planning and Goals of Care, Alberta
Health Services, Calgary Zone
Faculty/Presenter Disclosure
• Faculty: Amy Tan• Relationships with financial sponsors:
- Grants/Research support: Canadian Frailty Network; College of Family Physicians of Canada Foundation- Speakers Bureau/Honoraria: N/A- Consulting Fees: N/A- Patents: N/A- Other: N/A
Faculty/Presenter Disclosure
• Faculty: John You• Relationships with financial sponsors:
- Grants/Research support: Canadian Frailty Network- Speakers Bureau/Honoraria: N/A- Consulting Fees: N/A- Patents: N/A - Other: N/A
Disclosure of Financial Support
• This program has received financial support from Canadian Frailty Network, Hamilton Health Sciences Research Institute
• This program has received in-kind support from Ariadne Labs, Foothills Medical Centre, Hamilton Health Sciences, Sunridge Family Medicine Teaching Clinic (University of Calgary)
• Potential for conflict(s) of interest: None
Objectives
• Learn about the Serious Illness Care Program (SICP)
• Learn how to implement system change in your own setting
Format of workshop: interactive!
• Orientation to SICP and its implementation (large group)
• Customizing workflow (small groups)
• Modifying the electronic health record (mini “expert panel”)
• Choosing outcome metrics (small groups)
• Sharing our experience (large group)
Icebreaker
• Name and where you are from• Experience of SICP• Favourite midway food
9
The goal is simple: better care for patients
Where we are now Where we want to be
Doing some of the right things some of the time for some of our patients with serious illness
Doing the right things all of the time for all of our patients with serious illness
Tools
Education
Systems Change
Serious Illness Care Program
Measurement and Improvement (QI)
Reminder System
Conversation using the
Guide
Documentation template in EMR
Patient & Family
Resources
Patient Screening
Serious Illness Conversation Guide
Clinician ReferenceGuide
Patient preparation materials
Family Comm.Guide
Train Clinicians
2.5-hour clinician training sessions
Checklist + Language + Process
The intervention is feasible, acceptable and effective in stimulating more, better, and earlier conversations about serious illness goals
• Identifying the appropriate patients• Training program is adopted and viewed as effective by clinicians.• Reminder system stimulates discussions with a vast majority of
patients within 2 visits.• Patients and clinicians find the intervention acceptable.• The intervention results in more, better, and earlier conversations
about serious illness care values and goals.• The intervention results in more comprehensive and retrievable
documentation in the EMRPaladino J et al. JAMA Oncology. March 2019.
Results were null for receipt of goal-consistent care and peacefulness at EOL but showed
clinically important reductions in depression and anxiety
Bernacki R et al. JAMA Intern Med. March 2019.
Phase 1. Building a foundation
Physician Engagement Observed During a Surgical Checklist Implementation
What We Will Probably See With The Conversation Guide
The 1-on-1 Conversation:
A Path To Meaningful Implementation
Methods of Engagement
• Posters• Bulletin Boards• Large Meetings• Departmental Meetings • Emails• Hospital Newsletters• One-on-One Conversations
Serious Illness Guide Engagement
• Everyone who will be touched by the project should be engaged with at least 1 one-on-one conversation as we move beyond small-scale testing
• This includes: nurse practitioners, social workers, physicians, and others
Nothing Replaces this Conversation
• Staff meetings don’t count
• Emails don’t count
• Posters don’t count
• Bulletin boards don’t count
The 1-on-1 Conversation
• Shows respect
• Allows you to tailor the message to each individual
• Helps you gauge the readiness or resistance of each person
• Can help identify enthusiastic supporters who can help champion the work
Key Points In the 1-on-1 Conversation
• Introduce the guide
• Explain how the guide will change things
• Acknowledge that the person you are speaking to may already do this
• Share some of the benefits of the guide
• Tell them how important they are to the success of the project
• Explain how they are a leader and they can help set a positive tone with their colleagues
• Ask for help
• Thank them for their time
What You Might Hear…
• “I don’t need to do it. I already know what my patient wants”
• “There isn’t time to do this”
• “I don’t want to do it. I’ve never had to do this before and it makes me feel weird”
• “I need to stay focused and this is a distraction”
• “There is no evidence”
• “I already do this”
Phase 2. Plan Implementation
MONTREAL
HAMILTONCALGARY
Recruiting trainers: SICP “faculty” in Canada
VANCOUVER
OTTAWALONDON
Location NameVancouver Doris Barwich
Gillian FylesElizabeth Beddard-Huber
Vancouver Island Rachel CarterCalgary Jessica Simon
Amy TanAlexandra KushliakJennifer ZelmerAmanda Roze des Ordons
Edmonton Shelley Winton
Location NameHamilton John YouOttawa Peter MuneneMontreal Dev Jayaraman
Stefanie GingrasLouis BeaumierGolda TradounskyHarvey Chang
Nova Scotia Colleen Cash
Customizing workflow
Train
Identify
Cue
Prepare
Document
Time & Space
Follow on
PILOT PHASENov 2017- March/April 2018
Sunridge Family Medicine Teaching Clinic, Calgary, AB
Identify Patients >60 at high risk of needing medical
interventions/medical decisions and/or “frail” Visit 1 RA
with pt:
Visit 2-AHP with pt (ideally with SDM)
Pt Visit 3: MD visit with pt
(ideally with SDM)
Serious Illness Conversations (SICG) Training
Pilot Feasibility data collection w
Research Assistant:
PatientsSurrogate Decision-
makersClinicians
MD to receive scanned Dear Dr. letter & Tracking Record in EMR
inbox for review
After all 3 visits, patients will have completed:1) Personal Directive with SDM designation2) “Dear Dr” letter with Values questions from SICG and Best/Worst3) Alberta Health Services Goals of Care Tracking Record4) Alberta Health Services Goals of Care Designation Order (like MOLST/POLST)
iCAN-ACP Primary Care Pilot- Calgary
Small groups: How would you adapt these steps?
Identify
Cue
Prepare
Document
Time & Space
Documenting conversations:modifying the electronic health record
Templated Dictation
Standardized form: Paper and EHR
42
Prepare for monitoring and evaluationMeasures
• What would you measure to track uptake of the program?• What would you measure to know that the program is having the
desired impact?• Which measures would motivate clinicians to change behaviour?• Which measures are feasible in your local context?• How would you obtain these measurements?
Process Patient Clinician
Small groups: which metrics would you choose?
Phase 3. Launch and EvaluateResults from our implementation
Survey Results of Patients after 3 ACP Visit Pathwayn=8:
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
How well did you understand ACP How suitable to offer in family doctoroffice
Thoughts on how long visits took Good use of your time?
Appropriate
Just Right
ExtremelyWell 5/5
Quite a Lot (4/5)
Absolutelyappropriate
Extremely5/5
Quite a Lot (4/5)
iCAN-ACP Primary Care Pilot- Calgary
Survey Results of Patients after 3 ACP Visit Pathway n=8:
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
How emotionally upset did theseACP visits make you?
After visit 2 with SW, how readywere you to discuss with your FP?
After discuss ACP with your FP inVisit 3, how prepared do you feel re:
your ACP
Overall rating of the ACP process inyour FP office
Not at all
Slightly upset(2/5)
Excellent
Very Good
Moderately Upset
4/5
Extremely5/5
Quite a lot4/5
Somewhat
Quite a lot
4/5
Extremely5/5
iCAN-ACP Primary Care Pilot- Calgary
Survey Comments of Patients after
3 Visits:
Excellent process. Should be a standard process for all Family Dr’s to follow regardless of age of patient.
It is very important for me to have done this while my thinking is clear & also my family is well informed as far as my wishes are concerned.
Done very professionally and with great compassion & care.
Still need ongoing discussion about each item on graph. This will fully determine my agent’s responsibilities and my wishes. My agent would like to discuss with my niece in Edmonton, for clarification of my wishes.
Good process. Probably needs revisiting if health changes or every few years.
iCAN-ACP Primary Care Pilot- Calgary
Results: Process Outcomes
236 Conversations
179 Documented
49 Physicians trained
05
101520253035404550
Not at all Slightly Moderately Quite a bit Completely
Perc
ent (
%)
Patient/Family Member's Rating
Pre Post
Paired t-test: Significant mean increase 0.38 (95% CI: 0.136, 0.624) of feeling heard and understood after SIC (p<0.05)
“How much do you feel heard and understood by the doctors, nurses and hospital staff?”
pre and post SIC (n=79)
Clinician experience (n=27)
The Serious Illness Conversation Guide ...The Serious Illness Conversation Guide …
Promote the program
A doctor’s experience
Phase 4. Expand and Sustain
Spreading…
• Hamilton – Nephrology, Oncology, ICU
• Calgary - Hospitalists
Take away messages
• SICP is readily adaptable to different settings• Take the time to plan your implementation• 1:1 Engagement really matters
Tools you can useportal.ariadnelabs.org
