MOA role in End of Life
Care
(30 minutes)
1
2
Introductions
• Introduce yourself and, in a couple of words, your
role working with your GP in End of Life Care
during the action period
•
Example: “Created a registry.”
3
Identification
• Gut feeling
• Things you are
noticing
4
Assessment
• Recognize the impact that these tools may have
as patients reflect on their situation while they are
completing the tools. They need privacy.
• Engaging the family and community to better
assess the patient
• We want to give you some tips on ways
to introduce these tools. Refer to written
handouts.
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Seniors Assessment Tool
Edmonton Symptom Assessment Scale
Pain and Symptom Diary
Palliative Performance Scale will be completed
by the physician.
5
Seniors Assessment
Tool
Screening for
Distress
• When?
• How?
6
Edmonton Symptom Assessment Scale
7
Pain and symptom diary
8
Care Management
9
MOA Care Plan
Template
• Who are the primary
contact people?
• Current contact
information of all parties.
• Ensuring contact with
family
• How is the family
managing with
caregiving?
• What can you say?
What can’t you say?
10
Care management: Tools for toolkit
11
Engaging with community
<Customize this slide to your community >
• Identify resources available in the community and how to
contact them
 Home and Community Care - professional team and
HSW.
 Specialized palliative care services.
 Community supports: hospice societies, caregiver
support services, transport, meals, etc.
• Create an information package for patients and families
 Work with community providers to develop a kit for
patients …identify written materials and on-line sites.
 Where are additional resources found: local
libraries, resource centers.
12
Office methodology
• Huddles, pertaining to overall plan
• Patient specific huddles
• Processes
• Billing
13
Office methodology: Things to ponder…..
• When will your meetings
be?
• What supports do you
need?
• Who fits “The Surprise
Question”?
• What other tools will
help you?
• What will your registry
look like?
• What’s in your
community?
• Where will your toolkit be
kept?
• What is your billing
process?
• What else can you add to
your toolkit?
• Your comfort level,
how do you feel about
this?
14