What kind of things did your team do to improve care over time ?

Health Care Professional – South East: 

All consult nurses now have their certification. We make sure it’s a priority for them to keep updated with all the latest best practice guidelines in care. It’s a continuous strive to provide the patients with better service.

Helen Pyle – Lead Physician Ian Anderson House, Oakville, ON: 

We advocated for dedicated CCAC case managers to attend our meetings. We advocated for all the nursing agencies to mandate their palliative nurses to attend our meetings or bring reports from all their colleagues to our meetings. We encourage the nurses to bring up any concerns or questions about any aspect of the care of any patient on the team. We encourage any team member to bring any patient’s case to the team to be discussed once they have discussed the concept of the team with the patient and the patient has consented to be discussed. We have a set time and a central convenient location to make sure the meetings we host are as accessible as possible; we even get coffee donated. The only time when meetings are not held is over Christmas and New Year’s depending on what day of the week the holidays fall.

Palliative Nurse Practitioner – Niagara North: 

Use of technology is probably one of the best things. The bedside nurses know they can always get a hold of one of us. If we need help from the ER, we can call and tell them what is going on and get exactly what we need from them, and this enables us to continue facilitating care at home. We have access to clinical connect so we can see the hospital part of the patient journey.   I wish the hospital could see the CCAC notes on clinical connect so they have a better understanding of how to transition people from hospital to home without care gaps.

Clinical Navigator – Niagara North: 

Communicate! We talk to each other daily, sometimes even on weekends. We relay information to one another so that nothing falls through the cracks. We have a great system.

Health Care Professional – Central LHIN: 

We provide ongoing mentoring and support. We have an active journal club and interprofessional rounds and ongoing education sessions. We make sure there is 24/7 clinical nurse coordinator (CNC) support with management support of CNC staff. Collaborative working relationships with the inter-professional team including regular discussions with our medical director about best practice and challenging