Planning as early as possible for any patient healthy or not. It is stating one's wishes and preferences for future care in the event of an acute medical crisis or sudden health deterioration. An advance care plan may be used to guide the substitute decision maker and the healthcare team about what an patient would want or not want if they were unable to speak for themselves. Examples can include Representation Agreements and Advance Directives as well as informal conversations with family and friends. It is beneficial to do this in advance of a serious illness.
Adapted from: BC Ministry of Health, Advance Care Planning, Making Future Health Care Decisions.
AL (Assisted Living)
CHESS (Changes in Health, End-Stage Disease, Signs, and Symptoms)
An indicator that is used with the RAI tool, CHESS measures health instability and is a predictor of mortality in Home and Residential care settings. Your High Risk Indicator Report (HRIR) is set to note any patient with a 3 or more CHESS score.
EPAIRS (Embedding a Palliative Approach in Residential Settings)
GOC (Goals of Care)
Decision making in context of clinical progression/crisis/poor prognosis.
HoNOS (Health of the Nation Outcomes Scales)
This scale is used in community mental health and substance use teams to rate service users on their health or social status. The scale covers a wide range of health and social domains: psychiatric symptoms, physical health, functioning.
An indicator that is used with the RAI tool, MAPLe is a powerful predictor of admission to residential care and may indicate caregiver distress. It helps prioritize the patients who need community- or facility-based services and to help plan allocation of resources.
PLS (Provincial Language Services)
RAI-HC (Resident Assessment Instrument for Home Care)
An internationally researched and standardized assessment tool used primarily by Case Managers in Home Health to assess the care needs and health status of frail elderly adults and anyone with disabilities requiring supportive care. As a RAI assessor, this tool will help your prioritize the patients who may imminently need an early conversation and benefit from a palliative approach to care.
RPACE (Regional Palliatice Approach to Care Education Team)
SIC (Serious Illness Conversation)
Planning in the context of progression of serious illness.
SICG (Serious Illness Conversation Guide)
SPICT (Supportive and Palliative Care Indicators Tool)