Community Physicians Residence Background (Louie) ◦ Community physicians and the Dorothy Ley Hospice ◦ Patient referral process Continuity of care: A Case study ◦ Community ◦ Hospital ◦ Dorothy Ley Hospice inpatient Summary Discussion (Mary and Ruth) Toronto Grace Hospital (TGH) physicians ◦ 25 years in the Etobicoke community ◦ Patients primarily admitted to Toronto Grace Hospital TGH physicians association with Dorothy Ley Hospice (DLH) ◦ 4 core physicians expand into Etobicoke and Mississauga area ◦ Increasing preference by community patients to be admitted to DLH ◦ Growing presence of the TGH palliative physicians at DLH ◦ Formal association between TGH community physicians and DLH February 2014 The DLH Community Physicians ◦ Currently 10 physicians 3 fulltime and 7 part-time physicians Cover an area from downtown Toronto, Etobicoke and Mississauga ◦ ◦ ◦ ◦ ◦ Lead physician Monthly meetings Educational seminars (open to all) Mentoring On-call 24/7, 365 Patient Referral Process Referral Sources: 1. CCAC 2. Hospital a) Oncology b) CHF/renal c) other 3. Community Nursing 4. Family MDs 5. City of Toronto nursing homes SNR (single number reach) Triaged by MD who then initiates “palliative care services” Patient Referral Process Active patient roster updates Initiating “palliative care services” Administrative assistant Weekly meetings with community stake holders Patient Referral Process Challenges Addressed: 1. Multidisciplinary approach to patient care 2. Identifying needs of patients and families to initiate appropriate services 3. Information conduits to community stake holders for the DLH catchment area 4. Standardizing initial visit between patient and physician Community Experience ◦ Initial Referral May 2015 Care Coordination Spiritual Care Support Day Program Financial Guidance Social Supports Volunteer Visiting TCCCAC supports Toronto Central Nurse Practitioners Community Supports ◦ 1st Crisis May 2016 Allegations of Abuse in the home Moved to a Shelter ◦ 2nd Crisis July 2016 Respiratory Episode Admitted to St. Joes Hospital Experience ◦ July 6 Stabilized Plans to transfer back to Shelter ◦ July 20 Decline in status Plan for end of life and admission to Hospice DLH Inpatient Experience ◦ Referral July 20 ◦ Assessment for admission ◦ July 21 Admission Plans for funeral arrangements Family Meetings for End of life plans ◦ August 1 Condition Stabilized ◦ August 30 Development of a wound ◦ Sept 15 Family meetings to discuss Plan B with children Plan for LTC CCAC notified Physio initiated ◦ Late Sept/October Allegations of abuse Hyperactive Delerium? Calling frequently ◦ October 31 Formal Family Meeting CCAC Physician Executive Director Medical Director ◦ Nov 28 Condition fluctuating Receiving Active treatment Complex biopsychosocial situations require multidisciplinary approaches ◦ Stakeholders Community Physicians DLH (services and resources) In-home Care coordinators Volunteers Day program Residential CCAC et al Strengths and areas to improve
