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  1. MOA role in End of Life Care (30 minutes)

  2. 欢迎

  3. 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.”

  4. Identification • Gut feeling • Things you are noticing

  5. 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. • Seniors Assessment Tool • Edmonton Symptom Assessment Scale • Pain and Symptom Diary • Palliative Performance Scale will be completed by the physician.

  6. Seniors Assessment Tool Screening for Distress • When? • How?

  7. Edmonton Symptom Assessment Scale

  8. Pain and symptom diary

  9. Care Management

  10. 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?

  11. Care management: Tools for toolkit

  12. 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.

  13. Office methodology • Huddles, pertaining to overall plan • Patient specific huddles • Processes • Billing

  14. What supports do you need? What other tools will help you? What’s in your community? What is your billing process? Your comfort level, how do you feel about this? Office methodology: Things to ponder….. • When will your meetings be? • Who fits “The Surprise Question”? • What will your registry look like? • Where will your toolkit be kept? • What else can you add to your toolkit?