Sector Impact

Sharing Best Practices, Improving Care Plans

In February, Perley Health trained 18 healthcare professionals representing LTC homes from across Ontario during a virtual workshop. The topic: developing goals of care in collaboration with residents, families and care teams. The training was based on SeeMe®: Understanding frailty together, a method developed, implemented and evaluated at Perley Health.

“The session was extremely valuable,” says Alison Wilkes, RN and Assistant Director of Care, at East Holme, home to 128 LTC residents in Powassan, Ontario. “The training addresses a difficult challenge—having honest, meaningful discussions with residents and their families about frailty and quality of life, and then developing care plans that align with their preferences.”

The training was funded by Ontario Health, a Government of Ontario agency created to connect, coordinate and modernize the provincial healthcare system. Participants applied for the training through local partners, such as Champlain Hospice Palliative Care Program (CHPCP).

“We are excited to be able to capitalize on Ontario Health funding for organizations working with palliative care clinical coaches to offer this workshop,” says CHPCP Director Val Fiset.
SeeMe® enables residents, family and care teams to acquire the information and autonomy necessary to make key decisions about potential medical interventions, including transfers to hospital emergency rooms. Most importantly, the method empowers residents to live life on their own terms. In 2022, the Canadian Geriatrics Journal published the evaluation of SeeMe® completed by the Perley Health Centre of Excellence in Frailty-Informed Care™. The evaluation documents positive impacts on nurses, physicians and the families of residents in LTC.

To further improve goals-of-care decisions and care planning at homes across the country, Perley Health created a series of three e-modules, now available on Surge Learning, an educational website used by more than 600,000 LTC professionals. The modules, available as a supplement to the SeeMe® training package or as standalones, include: Goals of Care Conversations during Acute Health Events; Managing Conflict During Acute Health Events; Preventing Avoidable Emergency Department Transfers.

“LTC care homes face staffing challenges and there's little time for training, so evidence-based tools like these are really valuable,” says Alison Wilkes.

Daniela Acosta, Manager, Knowledge Translation at Perley Health (right) poses with Valerie Fiset, Director of the Champlain Hospice Palliative Care Program. The Program's support for the SeeMe® Framework and resources, along with the virtual workshop, will increase the ability of LTC staff to improve goals-of-care planning with residents and families.