Project Summary
The Continuity of Care for Palliative Services Project is a two year study that commenced in January 2005, and is co-sponsored by the MOH LTC.  It builds on the results of the project, “The Community Palliative Care Demonstration Project”, a collaborative initiative by The Ottawa Palliative Consortium (now Palliative Network) and led by Bruyère Continuing Care and the Ottawa Community Care Access Centre. It was aimed at providing a practical approach to optimize continuity of care for people at the end of life and their family caregivers. 
 
 
For more information contact: 

Frances Legault
University of Ottawa School of Nursing
613-562-5800 (8532)
Frances.Legault@uottawa.ca

 

Goal and Objectives
To implement and evaluate multiple interventions (service planning, physician referral and support, and communication) to optimize continuity of care in a community-based palliative care program.
 
The results of this project will provide a practical approach to optimize continuity of care. This approach could be applicable to care settings throughout Ontario as it builds on the existing health care system and does not imply additional funding. The proposed reorganization of services will strengthen collaborative relationships among health care providers through effective service planning and coordination, increasing family physician referral and support, and improving communication. 
 
 
Intervention 

1. A “Chart-in-the-Home”: a single convenient and accessible chart in the patients’ homes in which all health service providers and caregivers are asked to document.
   
2. CCAC service enhancements:  These will include a telephone call to the client from the Case Manager and a Nursing visit within 24 hours of admission to CCAC Palliative Program. A Quality Assurance Case Manager will monitor and promote consistency and continuity of care. The Oncology Unit of the Ottawa Hospital will provide a discharge envelope to study participants and fax a discharge summary to their family physicians.
   
3. Family physician access to palliative care expertise:  promoting 24/7 access to Palliative Care Pain and Symptom Management Team, as well as workshops and education sessions.

Principal Investigators 

Frances Legault, RN PhD, Assistant Professor, University of Ottawa, School of Nursing

Frances Legault is an Assistant Professor in the School of Nursing with teaching responsibilities in community health nursing in the Post RN program and interprofessional education in palliative care. Her program of research includes projects for community-based health services, end-of-life care for seniors and underserved populations, community health networks, and international health.

 
Co-Principal Investigator
Kevin Brazil, PhD

 
Co-Investigators and Decision Maker Partners
Sheila Bauer, RN, MHA
Liliane Locke, RN, MPA
Pippa Hall, MD, CCFP, MEd, FCFP       
Lynda Weaver, MHA, MEd

 
Staff                                                                
Susan Kasprzak, MA - Research Associate
Barbara Cameron, RN BScN - Research Assistant