Palliative Education and Care for the Homeless (PEACH): A Model of Outreach Palliative Care for Structurally Vulnerable Populations.

The Palliative Education and Care for the Homeless (PEACH) program comprises a community palliative care team serving some of the most complex clients in the healthcare system. Formal partnerships bring together physician, nursing, psychosocial and homecare, health and housing navigation supports. PEACH has served over 1,000 clients, leading field-defining research, medical education and public advocacy. The PEACH program demonstrates that innovation through deep interorganizational and intersectoral integration can drive value-based impact for the most complex clients, providing instructive lessons for public health system reform well beyond the margins faced by people who are unhoused. This paper describes how PEACH's unique model, critical community partnerships and research have been necessary for it to become a leader in community-based palliative care for structurally vulnerable people.

Exploring the Barriers and Facilitators Experienced by Palliative Health Care Providers Working with Patients Experiencing Homelessness during the COVID-19 Pandemic.

Background: Patients experiencing homelessness not only have higher rates of medical complexity, comorbidity, and mortality, but also face barriers to accessing palliative care services. In structurally vulnerable populations with palliative care needs, these barriers are compounded, creating significant challenges for both patients and providers that have important health equity implications. Objective: The aim is to explore the experiences of palliative care providers working with patients experiencing homelessness during the COVID-19 pandemic and understand the barriers they faced in providing care, as well as facilitators that aided in the success of their teams. Methods: Seven health care providers from two Canadian palliative outreach teams involved in delivering palliative care services to patients experiencing homelessness during the COVID-19 pandemic participated in audio-recorded and transcribed videoconferencing interviews. Analysis was completed using generic descriptive thematic analysis. Results: Five key themes were identified: (1) factors negatively impacting patient health, (2) use of technology, (3) care provider emotions, (4) care provider education and advocacy, and (5) outreach team factors. Conclusion: Identified barriers during the pandemic included worsening of existing patient vulnerabilities, as well as challenges incorporating technology into care. Providers faced increased emotional burden, with a rise in workload, stress, fear, and grief. However, several facilitators allowed teams to provide high-quality care to this vulnerable population, including team support, interprofessional collaboration, and advocacy and education initiatives. The outreach model also proved to be a highly flexible, resilient, and adaptable model for providing care during the COVID-19 pandemic.

Assessing the impact of a health navigator on improving access to care and addressing the social needs of palliative care patients experiencing homelessness: A service evaluation.

BACKGROUND: Health navigators are healthcare professionals who specialize in care coordination, case management, navigating transitions, and reducing barriers to care. There is limited literature on the impact of health navigators on community-based palliative care for people experiencing homelessness. AIM: We devised key performance indicators in nine categories with the aim to quantify the impact of a health navigator on the delivery of palliative care to patients experiencing homelessness. DESIGN: Data were collected prospectively for all patient encounters involving a health navigator from July 2020 to 2021 and reviewed to determine the distribution of the health navigator's role and the ways in which patient care was impacted. SETTING AND PARTICIPANTS: This study was conducted in Toronto, Ontario with the Palliative Education and Care for the Homeless (PEACH) Program. At any one time, the PEACH health navigator served a total of 50 patients. RESULTS: We identified five key areas of the health navigator role including (1) facilitating access (2) coordinating care (3) addressing social determinants of health (4) advocating for patients, and (5) counselling patients and loved ones. The health navigator role was split evenly between activities pertaining to palliative care for structurally vulnerable populations and community-based palliative care for the general population. To achieve high impact outcomes, a considerable investment of time and energy was required of the health navigator, speaking to the importance of adequate and sustainable funding. CONCLUSIONS: These findings underscore the potential for health navigators to add value to community-based palliative care teams, especially those caring for structurally vulnerable populations.

Factors That Determine the Experience of Transition to an Inpatient Palliative Care Unit for Patients and Caregivers: A Qualitative Study.

Objective: Transitions in care settings near the end of life can present challenges to patients and families, especially when there are also adjustments in level of care and illness trajectory. In this study, we explored what factors influenced how patients and family caregivers experienced a transition to an inpatient Palliative Care Unit (PCU). Methods: This qualitative study was conducted at a PCU in Toronto, Canada. Semi-structured interviews were held with 29 participants (14 patients and 15 family caregivers) during their time on the PCU. Data was analyzed through an iterative process of constant comparison to generate themes. The recruitment process continued to the point of thematic saturation. Results: Five themes were identified that represented the participants' experiences in transitioning to the PCU: Being prepared, Feeling supported, Coming to terms with end of life issues, Dealing with uncertainty, and Continuity of care. Conclusions: Our findings highlight the need for clear and iterative communication with patients and family caregivers during the transition to a PCU. Identification and consideration of the common themes involved in the experience of transfer to PCU can help guide future practice and improve the experience of patients and families during transitions at the end of life.

Management of Traumatic Hip Fracture in the Palliative Care Unit.

We report on the case of an elderly patient in a palliative care unit who fell and sustained a hip fracture. Hip fractures are potentially terminal events for elderly patients with other life-limiting conditions. The case highlights the need for more evidence to determine the best approach to care for hip fractures in patients who are in the final weeks or months of life.

Use of Standardized Assessment Tools to Improve the Effectiveness of Palliative Care Rounds: A Quality Improvement Initiative.

BACKGROUND: Optimal care for patients in the palliative care setting requires effective clinical teamwork. Communication may be challenging for health-care workers from different disciplines. Daily rounds are one way for clinical teams to share information and develop care plans for patients. OBJECTIVE: The objective of this initiative was to improve the structure and process of daily palliative care rounds by incorporating the use of standardized tools and improved documentation into the meeting. We chose a quality improvement (QI) approach to address this initiative. Our aims were to increase the use of assessment tools when discussing patient care in rounds and to improve the documentation and accessibility of important information in the health record, including goals of care. METHODS: This QI initiative used a preintervention and postintervention comparison of the outcome measures of interest. The initiative was tested in a palliative care unit (PCU) over a 22-month period from April 2014 to January 2016. Participants were clinical staff in the PCU. RESULTS: Data collected after the completion of several plan-do-study-act cycles showed increased use and incorporation of the Edmonton Symptom Assessment System and Palliative Performance Scale into patient care discussions as well as improvement in inclusion of goals of care into the patient plan of care. CONCLUSION: Our findings demonstrate that the effectiveness of daily palliative care rounds can be improved by incorporating the use of standard assessment tools and changes into the meeting structure to better focus and direct patient care discussions.

Effectiveness of the buccal mucosa route for methadone administration at the end of life.

BACKGROUND: Methadone is a useful analgesic for neuropathic and nociceptive pain. However, there is little information about the use of methadone in the final days of life when a patient cannot swallow, discouraging its use by many palliative care physicians. OBJECTIVE: The purpose of this study was to investigate the effectiveness of switching patients on oral methadone at the end of life to methadone by the buccal mucosa route. METHODS: This is a case series comprising 36 patients on the Toronto Grace Palliative Care Unit (PCU) who took methadone between 2010 and 2012. Their health records were retrospectively reviewed. When patients could no longer swallow at the end of life, oral methadone was replaced with methadone solution in a concentration of 10 mg/mL, placed in the space between the buccal mucosa and lower molars. RESULTS: Twenty-five patients met inclusion criteria for the series. Twenty-four (96%) of the patients tolerated methadone by the buccal route and were able to continue receiving it that way until they died. Methadone was discontinued by the buccal route in one case (4%) because of intolerance to having medication placed in the oral cavity. Of the patients who remained on buccal methadone, there was a need to increase the dose in two patients with the remaining patients taking the same dose of buccal methadone until they died. CONCLUSION: The cases reviewed suggest that methadone is well tolerated and effective when switched to the buccal route in patients at the end of life on a palliative care unit.