Perhaps more than most other areas of healthcare, palliative care depends on close, timely communications between all medical professionals and caregivers to provide clients with optimal care. In a hospital setting, where everyone is in one place, this is relatively easy to accomplish.
But the palliative care team at Toronto Central Community Care Access Centre (TC CCAC) faced a challenge: how to achieve hospital-level communication to support their in-home care?
Toronto Central CCAC has a strong palliative team serving an increasing number of people with terminal illnesses who want to stay at home as long as possible. Properly prepared, with supports and appropriate medication, dying at home can be the right choice for many people.
Palliative care team members include care coordinators, nurse practitioners and a pharmacist from TC CCAC, nurses and personal support workers from service provider organizations, and physicians from the Temmy Latner Centre for Palliative Care and Hospice Toronto.
When TC CCAC’s commitment to integrated care expanded to include palliative care clients, the palliative team and its partners had to come up with solutions to present itself to clients as a single team. The first step to appearing like one team was to act like one, and that meant ongoing communication about each client.
The Toronto Central CCAC Palliative Program looked at best practices for palliative homecare and found evidence supporting the use of daily morning meetings. When a trial of the technique using conference calls was first proposed, there was not much support for it. Team members worried it would take too much time away from client care, which none of them could afford to lose.
Adjustments were made along the way, and the morning meeting, now called ‘the huddle’, has become a daily conference call between all team members. A few principles are strictly followed: the meeting starts on time, takes no longer than 15 minutes, is moderated by the care coordinator and follows the SBAR technique when introducing a new client with a problem or update (Situation, Background, Assessment and Recommendation).
In evaluating and revising the huddle, Quality Improvement techniques were used, including tracking how many clients were discussed, how many calls were avoided, and the level of satisfaction of both professional participants and their clients. The huddle was first tested with teams from three of nine districts in Toronto Central’s catchment area.
At first, the teams thought the huddle was an extra task. But after one or two months, they couldn’t live without it.
The team found that one-11 clients were discussed per huddle, with a median of six. More striking, a median of nine calls were avoided per huddle. Team members, especially nurses, were no longer spending hours on the phone trying to track down other team members or get authorization from a doctor. The satisfaction of participants was increased and clients now actually understood the many people involved in their care were a single, integrated team.
TC CCAC care coordinator Leslie Randl found that “the huddles help increase trust between team members, and create a feeling of shared responsibility.”
Huddle discussions are limited to high-priority topics. A support worker may report that a client seems to be deteriorating, and is having difficulty breathing. As a result, a nurse may volunteer to go to the home right away. The physician may commit to visiting in the afternoon. A doctor may report the first signs of bedsores on a client’s back, and treatment is quickly agreed upon and a personal support worker sent out that day. With immediate dialogue and discussion, immediate action can occur, improving patient care.
“It’s valuable to get updates on patients that the RNs are seeing on a more regular basis, especially when a patient’s status is changing daily,” says Dr. Marnie Howe of the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital.
The initial success has led to plans to expand to all nine district teams. For team members, the benefits are significant. There is less stress and greater satisfaction. We’re more proactive. We love our work. And the huddles have been crucial to building the teams. Previously, we didn’t know each other. Now we often organize joint home visits, and go out for lunch once a month. We’re a real team.