Educate staff, residents, and families about the benefits of preventing ED visits and the services the home has to manage care within the home

• Enhance staff training on early recognition and management of common conditions that may result in ED visits, such as infections and dehydration
  Preview ED Observation Tool
• Educate staff on effective communication techniques between members of the health care team and external clinical supports about a resident’s condition
  SBAR Tool; SBAR example
• Strengthen fall prevention programs to reduce injury-related ED visits by using environmental modifications, regular assessments, and mobility aids
• Increase access to on-site diagnostic tools, tests, and treatments (e.g., x-rays, ultrasounds, bladder scanner, lab tests, intravenous therapy) to manage conditions within the home
• Introduce virtual consultations for nonurgent health concerns to provide residents with timely care
• Work collaboratively with clinical supports, such as nurse-led outreach teams at local hospitals, nurse practitioners supporting teams averting transfers, and on-site nurse practitioners, to deliver education, training, and clinical guidance to home staff and participate in decisions to transfer a resident to a hospital
• Enhance palliative approach to care within the long-term care home
  Strengthening a Palliative Approach in Long-Term Care
  LEAP – Learning Essential Approaches to Palliative Care offered by Pallium Canada
• Complete advance care planning and ensure all residents have up-to-date care directives to guide decision-making and reduce unnecessary hospital transfers
• Involve the resident and their family, care partner or substitute decision-maker in care conferences to review care plan goals and preferences, particularly around end-of-life care
  

Resources for Health Care Professionals

• Use evidence-based tools to identify residents who would benefit from a palliative approach to care
  The Ontario Palliative Care Network’s Tools to Support Earlier Identification for Palliative Care outline recommended tools that can be integrated into various care settings
• Implement an evidence-based model of care for providing palliative care in long-term care
  The Ontario Palliative Care Network’s Palliative Care Health Services Delivery Framework outlines recommendations to guide the organization and delivery of palliative care and includes a patient pathway
• Provide access to evidence-informed tools to support long-term care clinicians with palliative care delivery. Resources should include:
  Palliative care or comfort care order sets (typically, these are facility specific and established locally)
  Symptom management guides
  - e.g., The BC Centre for Palliative Care’s Inter-professional Palliative Symptom Management Guidelines, Ontario Health’s symptom management guidelines
  Resources to support serious illness conversations and Goals of Care discussions:
  - Ariadne Lab and the Dana-Farber Cancer Institute’s Serious Illness Conversation Guide
  - Advance Care Planning Canada’s Just Ask: A Conversation Guide for Goals of Care Discussions
  - Guide and template for Documenting Goals of Care discussions
• Consider supplemental education on pain and symptom management and skills training to support goal of care discussions to help build capacity within the home
• Build linkages with community palliative care partners to supplement long-term care staff and create more specialized palliative care knowledge and skills in long-term care homes. Providers and organizations to engage include: 
• • Palliative pain and symptom management consultants
  • Local hospice residences
  • Nurse-led outreach teams
  • Paramedics and palliative care programs