This indicator measures the proportion of home care patients with a progressive, life-threatening illness who have had their palliative care needs identified early through a comprehensive and holistic assessment.

Quality Improvement Plans (QIPs)

Effective

Outcome

Limitations to this measure include that the needs change over time; patients may have more than one home care episode; and needs may have been assessed in other settings. Assessment quality will not be captured, only completions.

Most palliative and end of life care is not done by palliative care specialists. It would not be sufficient to use palliative care referrals as a proxy for this indicator. Who are these at-risk patients? The patient populations may include • Patients nearing the end of life • Newly diagnosed, serious and life-limiting conditions • Newly diagnosed cancer • End-stage organ failure(s) • Frailty • Dementia • Multiple medical conditions • Existing condition with a new development Step 1: Early Identification: Ask yourself, what screening process is currently in place in our organization to identify patients with progressive, life threatening illnesses that may have palliative care needs? Early Identification: the Ontario Palliative Care Network’s Palliative Care Toolkit lists tools for reference for step one. Coming soon: the Ontario Palliative Care Network’s Early Identification Guide (reference will be updated when it becomes available). Some tools used in Ontario include the Gold Standards Framework (GSF) and Hospital-Patient One-Year Mortality Risk (HOMR). Some tools rely on the “surprise” question as an initial screen. A more comprehensive guide will be available soon from the Ontario Palliative Care Network about these tools. Step 2: Assessment of palliative care needs: Ask yourself, what process is currently in place in our organization to do a comprehensive assessment of palliative care needs? The InterRAI palliative care tool is the current assessment for palliative care needs in home and community care. Some LHINs also use other tools. Needs assessment tools are found in the Ontario Palliative Care Network’s Palliative Care Toolkit. Health Quality Ontario’s Palliative Care Quality Standard includes 13 Quality Statements. This indicator closely aligns with Quality Statement #1. There are several strategies for improvement included within the Innovative Practices Guides for Complex Patients, published by Health Quality Ontario. Codes: Existing codes are used to capture received palliative care services and not identification and assessment; therefore, we would not recommend using the existing codes as proxies.

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