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NorthThompsonValley

HospiceHouseFeasibilityStudy

June 30, 2015 North Thompson Valley Hospice House Society

Submitted by: Lions Gate Consulting Vancouver, British Columbia [email protected]

In association with:

Peak Solutions Consulting, Kamloops, British Columbia GenevaGroup Health Care Consulting, Victoria , British Columbia

North Thompson Valley Hospice House Feasibility Study

Executive Summary The North Thompson Valley Hospice House Society (NTVHHS, the Society) is seeking to provide hospice

services, and in particular, an in‐patient hospice palliative and end‐of‐life care (HPEOLC) licensed care

facility or housing option with care services for the citizens of the North Thompson Valley (NTV). It has

commissioned this report, the purpose of which is to provide a feasibility assessment of a hospice house

that would be located in the NTV.

In Canada, there has been considerable advancement in hospice palliative care standards and care since

2002 when the Government of Canada released its Canadian Strategy on Palliative and End‐of‐Life Care.

BC’s Provincial Framework for End of Life Care (2006) and End‐of‐Life Care Action Plan (2013) set out

the policy, standards and pathway to deliver quality hospice, palliative and end‐of‐life care. In the 2013

Throne Speech, the Government of BC promised to double the number of hospice, palliative and end‐of‐

life care beds in the province by 2020 (Province of BC 2013).

The NTV is geographically large but sparsely populated, with approximately 7,300 residents. Growth will

be marginal over the next 25 years, but the proportion of seniors will grow significantly and increase

demand for health care services and specifically hospice, palliative and end‐of‐life care (HPEOLC).

There are no dedicated palliative units in NTV; swing beds at Helmcken Memorial Hospital and Forest

View Place, both in Clearwater accommodate palliative patients. Local stakeholders indicate that there

are gaps in HPEOLC services in the NTV and that a setting that better supports patients, their caregivers,

families and friends would improve quality of life.

Three hospice options are evaluated in this report, each with its own advantages and disadvantages. The

Hospice Outreach option has the main advantage of being relatively low cost and easy to implement,

but it is does not meet NTVHHS’s objective of developing physical space. A Hospice House would bear

the highest costs and risk and be challenging to implement, notably in terms of fundraising, but it could

be done. An Enhanced Acute/Residential Room bears lower costs and risk than a separate hospice

house, while still delivering on the mandate to increase services. Each option can be considered feasible

given the right conditions; however, based on the evaluation of NTVHHS’s capacity, the region’s

capacity, logistical issues and risk, the enhanced room option would be favoured over either the hospice

house or status quo at this time.

As a follow‐up to this report, the NTVHHS should:

meet with key stakeholders in the NTV to help identify a preferred option and next steps;

develop a long term strategic direction that articulates how it intends to evolve as an

organization so there is a clear pathway for implementation; and

continue to qualify and update options so when a decision is made the research and body of

knowledge is current.


Definitions End‐of‐Life Care – the term used for the range of clinical and support services appropriate for dying

people and their families. The goal of end‐of‐life care is the same regardless of the setting – to

ensure the best possible quality of life for dying people and their families. It focuses on comfort,

quality of life, respect for personal health care treatment decisions, support for the family, and

psychological and spiritual concerns.

Hospice ‐ a specialized facility or house with services that focus on the palliation of chronically or

terminally ill patient's pain and symptoms, and often their emotional and spiritual needs.

Hospice Palliative Care – is a philosophy of care that stresses the relief of suffering and

improvement of the quality of living and dying. It helps patients and families to address physical,

psychological, social, spiritual and practical issues and their associated expectations, needs, hopes

and fears; prepare for and manage self‐determined life closure and the dying process; and cope with

loss and grief during illness and bereavement. Care can be provided in hospices and in individuals’

homes supported by professional hospice teams and volunteers.

Life‐Limiting Illness – term used to describe cancerous, non‐cancerous and chronic illnesses that can

be reasonably expected to cause the death of a person within a foreseeable future, reducing their

life‐expectancy.

Palliative Care – the specialized care of people who are dying – care aimed at alleviating suffering

(physical, emotional, psychosocial or spiritual), rather than curing. The term is generally used in

association with people who have an active, progressive and advanced disease, with little or no

prospect of cure. The goal is to improve quality of life for both the patient and the family and is

provided in a variety of locations, including people’s homes and community settings, hospices,

residential care settings and hospitals.

Population Needs‐Based Approach to Palliative Care – recognizes that individuals facing a serious

illness have different needs, based on their unique health conditions, stage of disease and

complexity of symptoms. Health care services and supports should therefore vary in type and

intensity to most effectively meet the needs of the individual within a given population.


Abbreviations ALC ................................................................................................................... Alternative Level of Care

BCHPCA ........................................................................................ BC Hospice Palliative Care Association

CHPCA ............................................................................... Canadian Hospice Palliative Care Association

COPD ........................................................................................ Chronic Obstructive Pulmonary Disease

IH ................................................................................................................................... Interior Health

NHPCO ...................................................................... National Hospice and Palliative Care Organization

NTV ..................................................................................................................... North Thompson Valley

NTVHHS .........................................................................North Thompson Valley Hospice House Society

HPEOLC ....................................................................................... Hospice Palliative and End‐of‐Life‐Care

UK ................................................................................................................................. United Kingdom


Table of Contents 1 INTRODUCTION ....................................................................................................................... 1

1.1 Background 1

1.2 Purpose of the Report 1

1.3 Terms Used in This Report 1

1.4 Structure of the Report 2

2 NATIONAL AND INTERNATIONAL CONTEXT FOR HOSPICE PALLIATIVE AND END‐OF‐LIFE CARE 3

2.1 The International Context: Leaders in Hospice Palliative and End‐of‐Life Care 3

2.2 The Canadian and BC Context 4

2.3 The BC Context 5

3 NORTH THOMPSON VALLEY COMMUNITY BASELINE AND AVAILABLE HOSPICE PALLIATIVE

CARE SERVICES ...................................................................................................................... 11

3.1 Community Baseline 11

3.2 HPEOLC Services by Interior Health 20

3.3 Physicians and the delivery of Medical Care to HPEOLC Patients in the NTV 24

3.4 Local Attitudes Toward Health Services 25

3.5 Hospice Societies in the North Thompson Valley 26

4 NEEDS ASSESSMENT .............................................................................................................. 30

4.1 Estimate of Demand 30

4.2 Gaps Assessment 31

5 FEASIBILITY ASSESSMENT ...................................................................................................... 34

5.1 Potential Delivery Models 34

5.2 Demand and Regulatory Considerations 34

5.3 Defining the Options 35

5.4 Evaluating the Options 39

5.5 Exploration of Sub‐Options 42

6 CONCLUSIONS AND RECOMMENDATIONS ............................................................................. 47

6.1 Conclusions 47

6.2 Recommendations 49

7 REFERENCES .......................................................................................................................... 51

7.1 Literature Cited 51

7.2 Personal Communications 53


June 30, 2015 Project No. V14F84

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1 INTRODUCTION

1.1 BACKGROUND

The North Thompson Valley Hospice House Society (NTVHHS, the Society) is a registered non‐profit

society, established in 2011 to raise money and awareness around hospice care in the North Thompson

Valley (NTV). All members of the Society’s board are volunteers and their efforts over the years have

already raised funds in support of services through community fundraisers like antique appraisal events

and bike races. The Society is seeking to provide hospice services, and in particular, an in‐patient hospice

palliative and end‐of‐life care (HPEOLC) licensed care facility or housing option with home care services

for the citizens of the NTV.

In 2014, the Minister of Health awarded a grant to the Society so it could review the need for the

delivery of in‐patient hospice services in the area, develop sustainable strategies for those services, and

determine a timeline for fundraising and planning.

1.2 PURPOSE OF THE REPORT

The purpose of this report is to provide a feasibility assessment of hospice housing options that would

be located in the North Thompson Valley. The Society has identified the following research objectives:

Demographic information, including current and projected population statistics for British

Columbia, Canada, and the NTV;

Assessment of the current hospice services provided in the NTV;

A gap and needs analysis of current and projected hospice services for BC and the NTV;

Description of different models of residential hospice care provided in rural North American or

International settings, and recommendations as they apply to the NTV;

Assessment of potential overlap of other related services;

Recommendations for the feasibility of a residential hospice care program in the NTV;

Administration and staffing that would be required;

Capital costs (facilities & equipment); and,

Financing and potential funding required to move forward.

1.3 TERMS USED IN THIS REPORT

Documentation reviewed as part of this study use many different terms to describe care at the end‐of‐

life, among which include hospice palliative care, palliative care, end‐of‐life care, and hospice palliative

and end‐of‐life care (HPEOLC). For the purpose of this report, all are used interchangeably to mean a



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range of end‐of‐life care services delivered to individuals with life‐limiting illness and their families on an

out‐reach or in‐patient basis in a variety of settings.

1.4 STRUCTURE OF THE REPORT

Chapter 2 outlines the national and international context for hospice palliative and end‐of‐life care

services (HPEOLC) in British Columbia.

Chapter 3 presents baseline community data and availability of HPEOLC services in the North Thompson

Valley, while Chapter 4 presents a needs assessment and potential service models for the region.

Feasible options for the provision of hospice palliative services are discussed in Chapter 5, and a study

summary is provided in Chapter 6.

Reference materials used in this report, including literature cited and personal communications, are

noted in Chapter 7.



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2 NATIONAL AND INTERNATIONAL CONTEXT FOR HOSPICE

PALLIATIVE AND END‐OF‐LIFE CARE

2.1 THE INTERNATIONAL CONTEXT: LEADERS IN HOSPICE PALLIATIVE AND END‐OF‐LIFE

CARE

2.1.1 The United Kingdom (UK): From Dame Cicely Saunders to the Gold Standard

In 1967, Dame Cicely founded St. Christopher's Hospice, with a focus on care for the dying including

expert pain and symptom control, compassionate care, teaching and clinical research. St. Christopher's

was the birthplace of the modern hospice movement, which largely served patients with terminal

cancer. It continues to be a pioneer in the field of palliative medicine now established worldwide.

More recently, in 2000, Dr. Keri Thomas of the UK brought the Gold Standards Framework (GSF) to the

world of palliative care in acute, residential and hospice settings. Now, HPEOLC practitioners in Canada

are using the GSF as a definitive guide to measure and improve palliative education and care.

2.1.2 Australia: Ensuring Patients with Life‐threatening Illness are Identified Sooner

In the last decade, Australia has been recognized for its work to ensure individuals with life‐limiting

illness and their families are identified and offered supportive HPEOLC services sooner, to improve or

maintain their quality of life as symptoms evolve. To do this, Australia has focused on practitioners

learning about and using ‘the palliative approach’ for their patients with life‐limiting illness who are not

yet needing palliative care but may be at risk of dying in the same or next year. The belief is these

patients, once identified, will benefit from referrals for services such as pain management, emotional

support, and hospice outreach services to name a few.

Second, Australia has been promoting the use of the palliative approach not only with individuals who

have cancer but also those with non‐cancerous, life‐limiting conditions such as Chronic Obstructive

Pulmonary Disease (COPD), heart failure (HF), severe dementia and others. The belief is that all patients

nearing the end of their lives and suffering with life‐limiting illness can benefit from earlier referral to

HPEOLC services and not only those with cancer. Research has shown that for some, their quality of life

and life‐span can increase as a result.

The UK, Canada and other countries are studying the palliative approach and supporting their

practitioners and HPEOLC service providers to identify individuals with life‐limiting illness sooner. In

British Columbia, the Initiative for a Palliative Approach in Nursing: Evidence and Leadership (IPANEL) is

conducting research into the palliative approach and what it means to nurses in various settings,

including urban and rural locations, with a view to improving the delivery of HPEOLC.



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2.2 THE CANADIAN AND BC CONTEXT

2.2.1 Health Canada’s Secretariat on Palliative and End‐of‐Life Care: Initiating Consensus

The Canadian Strategy on Palliative and End‐of‐Life Care was released in 2002. The impetus for the

strategy was Health Canada's Secretariat on Palliative and End‐of‐Life Care when it hosted over 150

national, provincial, territorial and regional practitioners, researchers and decision makers in palliative

and end‐of‐life care for a three‐day workshop in 2002. Participants from across Canada considered

priority end‐of‐life care areas and reached a consensus on five key areas, resulting in the establishment

of five Working Groups:

Best Practices and Quality Care

Education for Formal Caregivers

Public Information and Awareness

Research

Surveillance

These five Working Groups led the primary initiatives of the Canadian Strategy on Palliative and End‐of‐

Life Care. In 2007, the Secretariat was replaced by Health Canada’s Palliative and End‐of‐Life Care Unit

The unit is the focal point for issues faced by Canadians who are dying or dealing with life‐limiting

illnesses. It ensures that palliative and end‐of‐life care is taken into consideration in relevant policy

initiatives at the federal level, and works with provincial and territorial partners and key stakeholders

regarding end‐of‐life care issues.

In 2004, through the First Ministers Meeting and 10 Year Plan to Strengthen Health Care, funding was

given to the provinces and territories to improve, among other goals, the access and delivery of

palliative care to individuals at home in the community. Through this initiative, BC’s health authorities

began to provide home support services at no cost to eligible individuals deemed palliative and in the

last six months of life.

2.2.2 The Senate of Canada and Health Canada: Setting the Bar

In 2009, the Senate of Canada’s Committee on Aging stated it is important for society to support people

to age and die in the place of their choice. It is well known that the majority of Canadians would prefer

to die at home. In BC, approximately 50% to 60% of deaths annually occur in acute care hospitals,

about 30% die in residential care facilities, and the remainder die in hospices, at home or other

locations.

Through the efforts of Senator Sharon Carstairs, several other reports specific to HPEOLC have been

released by the Senate. They provide analyses and recommendations over time with a focus on

improving the availability of, and access to, quality HPEOLC services for all Canadians. These reports

continue to influence governments and decision‐makers at national and provincial/territorial levels to



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invest in quality, person‐centred services for Canadians with life‐limiting illness and their families

throughout the end‐of‐life care journey.

2.2.3 The Canadian Hospice Palliative Care Association: Leading the Way

The Canadian Hospice Palliative Care Association (CHPCA), established in 1991, is the national voice for

Hospice Palliative Care in Canada. Advancing and advocating for quality end‐of‐life/hospice palliative

care in Canada, its mission is to advocate for national policy and standards for HPEOLC, and promote

public education and awareness. Its volunteer Board of Directors is composed of hospice palliative care

experts and volunteers from Canadian provinces and territories as well as members‐at‐large.

CHPCA works with provincial hospice palliative care associations and governments, and national

organizations such as the Canadian Home Care Association to define and promote standards for hospice

palliative care. In 2013, CHPCA released an update to its 2002 ‘Norms of Practice’ publication, called A

Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice (CHPCA

2013a). This document is widely used and acclaimed as Canada’s standard for integrated, quality

hospice palliative and end‐of‐life care. CHPCA also provides a variety of educational resources for

patients, families, practitioners and organizations involved in HPEOLC.

2.3 THE BC CONTEXT

2.3.1 Provincial Framework for End‐of‐Life Care in British Columbia: Recommended Key Services

In its Provincial Framework for End of Life Care (BC Ministry of Health 2006; the Framework), the

Government of British Columbia committed to establishing high quality end‐of‐life care and support as

an integral part of the provincial health system. It proposed to work with health authorities, service

providers and community groups to build on existing services to create a system of exemplary end‐of‐

life care. The Framework acknowledges that the majority of BC residents die in hospital even though

many would prefer to do so at home or in a hospice. To help health authorities design their HPEOLC

programs, the Framework mandates the following approaches and key services each health authority

should provide:

Cycle of Care – this holistic approach links all stages of end‐of‐life care (assessment, information

sharing, decision making, care planning, care delivery, confirmation) into a process cycle.

Different stages receive more or less emphasis, depending on the nature, scope and timing of

the service being provided, but the expected outcome is better end‐of‐life care.

Home‐based Care – this involves assessment of the patient and family by a Registered Nurse to

support preparation to receive end‐of‐life care, and may include advance care planning.

Information on the patient’s illness, clinical needs and service options such as home support is

disseminated. The patient’s care is coordinated by the nurse with an interdisciplinary team

including a physician or Nurse Practitioner. Other key elements include pain and symptom

management, psychosocial, spiritual and bereavement support, and support for the family



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including financial and administrative guidance to access programs such as the BC Palliative Care

Benefits Program.

Specialized Support and Backup – family, patient and care providers involved with HPEOLC

need access to specialized consultation and support services such as crisis response, specialist

consultation and patient and family support.

Access to Specialized Hospitals and Hospices – access to hospitals and hospices is meant to be

provided in a coordinated, integrated manner. Approximately one third of residents in

residential care facilities die there. Many others could spend their remaining time in residential

care and not die in hospital if advance care planning and access to HPEOLC were provided and

easily accessed in residential care instead. Care in a hospice is appropriate for those who need

regular assessment and treatment changes that do not require the full facilities of a hospital,

where services cannot be provided at home, or where the patient does not wish to die at home.

Hospital‐based Services – enhanced community services would not eliminate the need for acute

specialized palliative care for those who need frequent, specialized assessments, treatments and

medications.

System Characteristics and Organization – the above‐noted services should be organized,

coordinated and delivered to keep the system efficient and effective while improving underlying

quality of life for patients and their families. Key supporting elements including the coordination

of an interdisciplinary team with a leader and clear communications protocol, support for

professional caregivers, information on end‐of‐life care systems procedures, options and

available support, basic and continuing education for all health professionals involved in end‐of‐

life care, and finally, ongoing research and evaluation between education institutions and

service providers that stimulate improvements and innovation in end‐of‐life care. (BC Ministry

of Health 2006)

2.3.2 Provincial End‐of‐Life Care Action Plan for British Columbia – Improving Access and Quality

The Provincial End‐of‐Life Care Action Plan (Ministry of Health 2013; the plan) is the BC government’s

plan to actualize end‐of‐life care policy articulated in Provincial Framework outlined above. The plan is

meant to prioritize the strategic development and delivery of quality hospice, palliative and end‐of‐life

care across the province. The plan has the following three priorities:

Redesign health services to deliver timely, coordinated end‐of‐life care.

Provide individuals, caregivers, health care providers with palliative care information, education,

tools and resources.

Strengthen health system accountability and efficiency.

The redesign of health services especially has implications for the provision of HPEOLC in communities

where it is intended to improve access to a range of services currently available only in larger centres.



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Specifically, a key directive is to improve the capacity to provide quality end‐of‐life care in residential

care facilities and other housing and care settings. A significant promise was made by Government in the

2013 Throne speech when it stated an intention to double the number of hospice, palliative and end‐of‐

life care beds in BC by 2020 (Province of BC 2013). The plan also promotes identifying individuals sooner

who may benefit from a palliative approach, as discussed earlier.

2.3.3 Current HPEOLC Programs and Services Available in British Columbia

The Provincial Home and Community Care Program

Publicly‐subsidized home and community care services provide a range of health care and support

services for eligible individuals who have acute, chronic, palliative or rehabilitative health care needs.

These services are designed to complement and supplement, but not replace, an individual’s efforts to

care for herself with the assistance of her family, friends and community. Home and community care

services can assist on a short‐term or long‐term basis depending upon the individual’s needs. The range

of services includes community nursing, community rehabilitation and home support services, as well

as adult day services and respite care, assisted living services and residential care services.

Home and community care services are intended to:

help individuals remain independent and in their own homes for as long as possible;

provide care at home when a person would otherwise require admission to hospital or would

stay longer in hospital;

provide assisted living and residential care services if a person can no longer be supported in

their home; and

support a person and their family if they are nearing the end of their life, at home, in an assisted

living residence or a residential care facility, which includes hospice. (Government of BC 2015)

Each regional health authority receives provincial funding to deliver a range of home‐based services for

eligible residents, in consideration of the health authority’s unique population, geography and other

considerations.

The BC Palliative Care Benefits Program

The BC Palliative Care Benefits Program is available for all eligible British Columbians in every health

authority. The program supports residents of any age who have reached the end stage of a life‐limiting

illness and want to receive medically‐appropriate palliative care at home. ‘Home’ is wherever the person

is living, whether in their own home, with family or friends, in an assisted living residence or in a hospice

that is not a licensed residential care facility covered under PharmaCare Plan B.

The intent of BC Palliative Care Benefits Program is to allow patients to receive palliative care at home

rather than be admitted to hospital if they so wish. The program gives palliative patients access to the



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same drug benefits they would receive as if in hospital, and access to some medical supplies and

equipment from their health authority.

The program includes full coverage of approved medications and equipment and supplies, upon referral

to, and assessment by the health authority where the person resides. (BC Ministry of Health 2014)

2.3.3.1 Specialized Palliative Care Services

These are HPEOLC services delivered to patients with unstable, medically complex conditions who

require access to special treatments and therapies to manage their symptoms and conditions. Usually

physicians, nurses and other members of the health care team who deliver specialized palliative care

services have additional education and experience in assessing and treating individuals with life‐limiting

illness. The BC Provincial Framework for End‐of‐Life Care and the CHPCA agree that access to specialized

palliative care services is a key service that individuals nearing the end of life need when their symptoms

cannot be adequately managed or controlled.

2.3.4 The BC Hospice and Palliative Care Association

BC Hospice Palliative Care Association (BCHPCA) is a not‐for‐profit, membership organization, which has

been representing individuals and organizations committed to promoting and delivering HPEOLC to

British Columbians since 1986. BCHPCA members provide a broad range of volunteer services to British

Columbians who are dying and their grieving loved ones in all regions of the Province.

BCHPCA’s mission is to lead in:

promoting responsive, quality hospice palliative care in British Columbia;

educating British Columbians on advance care planning; and

advocating for equitable access to responsive, quality HPEOLC.

Strategic goals include engaging and educating British Columbians about responsive, quality care and

advance care planning, and developing resources with its partners to discuss, document, and register

their advance care plans. The BCHPCA values BC’s hospice societies and their volunteers, and offers

support to them in a variety of ways informed by the membership.

2.3.5 The Range of Services Provided by BC’s Hospice Societies

BC’s hospice societies are numerous and provide a range of highly valued services to those who are

dying and their families, during the end of life phase and through the grieving process. In its 2013

Survey, BCHPCA found that more than half (57%) of the organizations describe themselves as “Hospice

society without beds providing psycho‐social support.” The second most common type of organization

(20%) was “Hospice society with beds affiliated with acute hospital.” There was only a handful of free‐

standing hospices affiliated with acute or residential care beds. There were no evident correlations

between either service area population or health authority and the type of organization. That is, all

regions were represented by different organizational types. (BCHPCA 2014)



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In terms of services provided, survey results are presented in Table 1. A total of 20 services were

identified. The services most likely to be provided were educational resources anticipatory grief

support, vigil support, companionship, palliative 1:1 support and grief/bereavement support. Less

than half the respondents offered home‐based palliative care.

Table 1 Services Offered by Hospice Societies by BC Health Authority

FH IH NH VCH VIH Yukon Total %

Disease /symptom management 1 3 2 0 3 0 9 18

Palliative 1:1 Support 8 12 6 1 10 1 38 78

Home‐based palliative care 1 10 3 1 7 0 22 45

Physical support 1 2 2 1 2 0 18 16

Spiritual support 7 12 4 0 10 1 34 69

Anticipatory grief support 6 16 6 2 10 1 41 84

Grief/ Bereavement 1:1 6 10 3 1 10 1 31 63

Grief/ Bereavement support 8 12 5 3 9 1 38 78

Vigil support 8 14 5 3 10 1 41 84

Practical support 3 9 6 0 8 0 26 53

Companionship 8 15 5 3 9 0 40 82

Day programs 3 2 0 2 2 0 9 18

Respite care 3 5 3 2 6 0 19 39

Complementary therapies 8 10 4 2 10 1 35 71

Caregiver support clinics/ groups 7 5 0 2 7 1 22 45

Professional education 4 6 3 1 10 1 25 51

Community education 8 15 6 3 10 1 43 88

Lending libraries 8 16 6 2 9 1 42 86

Advance care planning support 2 11 3 1 9 0 26 53

Other 4 3 2 1 6 0 16 33 Source: BCPHCA (2014) Notes: FH Fraser Health, IH Interior Health, NH Northern Health, VCH Vancouver Coastal Health, VIH Vancouver Island Health



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Figure 1 The Heart of Hastings Hospice Case Study

Overview

The Heart of Hastings Hospice is a community‐based, volunteer, in‐home service, dedicated to meeting the needs of individuals and their families who are facing the terminal phase of their illness. Their Hospice home is located in Madoc. The Hospice serves the Ontario municipalities of Centre Hastings, Marmora and Lake, Tweed, Tudor and Cashel, and the Townships of Madoc and Stirling‐Rawdon. The Hospice services a rural area of approximately 22,000.

History

The Hospice traces its begins back to 1990 when thirteen area residents formed a Provisional Board for the purpose of establishing a hospice. For the past 25 years the Heart of Hastings Hospice has continued to provide in‐home palliative care and support, and bereavement support for members of bereaved families. Beginning in its 2012 the Board of Directors decided to purchase a dedicated hospice house ‐ a Hospice House that provides care and support to people approximately one month away from the end of life. The Hospice House provides an option for terminally ill patients to live their last days in a quiet home‐like setting, if for some reason they are not able to spend their last days in their own home.

A fundraising campaign was launched in 2011, and within 12 months $240,000 had been raised. An anonymous donation of $ 100,000 plus $ 75,000 from the John M. and Bernice Parrott Foundation provided a solid base, with the balance coming from individuals, businesses, churches, and service clubs within the six communities served by the Heart of Hastings Hospice. In addition, support from the Ontario Trillium Foundation addressed interior wheel chair access, hospital beds and fire sprinkler system costs. The Community Futures Development Corporation assisted with mortgage funding. Donors also gave pledges to meet House operating costs over the first two years of operation. Work continues to cover the remaining costs which amount to $ 55,000, through events and contributions.

Hospice House Operation

The home has two bedrooms and since opening in 2012, approximately one person per month has stayed at home. To February 2015 there has been 27 people at the end‐of‐life stay in the home with this number reflecting numbers that are in line with Canadian per capita rates anticipated per 100,000. The home is operated by volunteers who attend during the day. In addition, the home has a contract with the provincial health authority to provide a Personal Support Worker (PSW) to be present overnight when a patient is in the home. Home care nurses attend to patients as they would attend to a person living in their own home.

There is no charge to use the home and the Hospice house has no stable funding and relies on community donations with the Hospice asking family members who pass to think about making donations and formal fund raising program. Overall, fund raising has gone well now that the home is formally opened and the community begins to identify with the home.

The 2015 budget specifically to operate the Hospice House is approximately $55,000 which includes covering ¾ of the wages of the Hospice House director. However, this is not the total cost of operating the house as the Heart of Hasting Society also has other in‐community programming that is based out of the home as well.

Source: The Heart of Hastings Hospice (2015); Quinn 2015, pers. comm.



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3 NORTH THOMPSON VALLEY COMMUNITY BASELINE AND

AVAILABLE HOSPICE PALLIATIVE CARE SERVICES

3.1 COMMUNITY BASELINE

3.1.1 Location

The North Thompson Valley, located in

the Central Interior of British Columbia, is

so named after the North Thompson

River. The River and Valley originate in

the Cariboo Mountains west of

Valemount and flows generally south

towards Kamloops and the confluence

with the South Thompson. For most of its

length, the river is paralleled by Highway

5, and the Canadian National Railway.

Major communities linked by the

highway include Blue River, Avola,

Vavenby, Clearwater, Little Fort, Barriere

and Louis Creek.

The Study Area for this report is defined

as North Thompson Valley communities

with a southern terminus of McLure (just

south of Barriere) and a northern

terminus of Blue River (Figure 2).

3.1.2 Communities

There are six major communities in the

North Thompson Valley, only two of

which are incorporated: Barriere and

Clearwater. The two municipalities and

the surrounding rural areas form part of

the Thompson‐Nicola Regional District

(TNRD), which is headquartered in Kamloops. Local government services in unorganized rural areas are

managed via three electoral areas: Thompson Headwaters (Area “B”), Wells Gray Country (Area “A”) and

Lower North Thompson (Area “O”).

Barriere is located 66 kilometers north of Kamloops on Yellowhead #5 Highway. It is situated at the

confluence of the Barriere and North Thompson Rivers in the Central North Thompson Valley. The

Figure 2 The North Thompson Valley

Source: NTValley.com (2014)



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Shuswap Highlands mark the eastern side of the valley, rising to 1,830 meters. The predominant

industry in Barriere is forestry. Two mills are located in the area: Gilbert Smith Forest Products (Barriere)

and North River Log Homes (Darfield). Approximately 75% of the area's labour force is either directly or

indirectly dependent upon the forest industry.

Little Fort is situated at the junction of Highway #24 and Yellowhead #5 Highway, 30 kilometers north of

Barriere. The economy consists of traditional businesses such as hay and cattle farms, restaurants, hotel,

campground, pub, gas station, general store, craft store and fly and tackle shop. The community does

not have a major employer.

Clearwater, located 124 kilometers north of Kamloops, is the largest community in the North Thompson

Valley. The predominant industry in Clearwater is forestry, but as the gateway to Wells Gray Provincial

Park, tourism is also an important sector. The park encompasses 522,000 hectares, with five major lakes,

two large river systems, numerous major waterfalls and many prominent topographical features.

Vavenby is located 27 km northeast of Clearwater. Vanvenby is the location of a Canfor sawmill and

despite a downturn in the forestry sector locally, it remains an important contributor to the economic

base. Recreation in the community consists mainly of outdoor activities, the most popular being

snowmobiling, horseback riding, hiking and fishing.

Avola is located 40 km south of Blue River. The community is almost entirely dependent on the forestry

industry with Weyerhaeuser and Slocan lumber mills being the major employers. Businesses in Avola

include a restaurant and gas station, motel and pub. Home based businesses consist of logging and

trucking companies.

Blue River is approximately half way between Vancouver and Edmonton (230 kilometers north of

Kamloops and 212 kilometers south of Jasper). The Valley narrows here with the Monashee mountains

on the east and the Cariboo mountains on the west. Located in an area filled with lakes, rivers, streams,

and forests, Blue River's economy is driven by forestry and tourism. Mike Wiegele's Helicopter Skiing is a

major employer and destination for international ski visitors. (NTValley.com 2014)

3.1.3 Population

Table 2 outlines the population by the two incorporated communities of Barriere and Clearwater and

the three Electoral Areas of the Thompson‐Nicola Regional District that make up the study area.

Barriere and Clearwater incorporated as municipalities in 2008. Prior to that, the population of

Clearwater was part of Electoral Area A, while the population of Electoral Area O was home to the

residents of Barriere. Overall, the population in the North Thompson area has declined by 9.5 percent

over the ten year period between 2001 and 2011.



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Table 2 Study Area Population By Community and Electoral Area (2001 and 2011)

2001 2011

Barriere 0a 1,777

Clearwater 0a 2,334

TNRD A 4,399a 1,536

TNRD B 368 283

TNRD O 3,257a 1,335

Total 8,024 7,265Source: Statistics Canada Note a: Barriere and Clearwater were not incorporated in 2001

3.1.4 Population Projections

3.1.4.1 Historical and Projected Percentage Change in Population

Figure 3 outlines the change in percentage population for the North Thompson LHA, Kamloops LHA and

British Columbia for the period from 1986 to 2041.

Figure 3 Percentage Population Change for Kamloops LHA, North Thompson LHA, and British Columbia (1986 to

2041)

Source: BC Stats (2014)

80.0%

90.0%

100.0%

110.0%

120.0%

130.0%

140.0%

150.0%

160.0%

170.0%

180.0%

190.0%

200.0%

210.0%

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

2018

2020

2022

2024

2026

2028

2030

2032

2034

2036

2038

2040

Kamloops LHA North Thompson LHA British Columbia



14 | P a g e

As illustrated, the population for the North Thompson LHA peaked in 1996 and declined rapidly until

approximately 2006. Between 2006 and 2014 the population has made modest increases but remains

below its peak in 1996. Conversely, the province experienced continual population growth over the

1986 to 2014 period, while the Kamloops LHA has trended up over the same period with a slight lag in

growth that was experienced between 1996 and 2006.

3.1.4.2 Projected Percentage Change in Population

Looking ahead to 2041, it is anticipated that the North Thompson LHA will see further modest recovery

in population; however, the population will still remain about 90% of the level experienced in 1996. This

is a much different picture than that at the provincial level which will have doubled over the 1986 to

2041 period, with strong growth projected to continue between 2014 and 2041. The Kamloops LHA is

also anticipated to show sustained growth over the period 2014 to 2041; although this will be at a rate

slightly less than that enjoyed at the provincial level.

3.1.5 Age Characteristics

Table 3 outlines the total population by age categories for the North Thompson Valley (North Thompson

LHA and Barriere) for the period between 2001 and 2041. As illustrated, the population over the age of

65 is anticipated to increase from 1,276 in 2011 to 2,340 in 2021. After 2021, the over 65 age population

is anticipated to decline, with 2031 projected to have 2,205 residents over 65 years of age.

Table 3 North Thompson Valley Historical and Projected Resident Counts By Age (2001 to 2041)

2001 2011 2021 2031 2041

Age

0‐19 2,299 1,577 1,357 1,422 1,493

20‐44 2,759 1,733 2,046 2,310 2,159

45‐64 2,175 2,679 2,105 1,617 1,852

65‐74 537 818 1,206 1,144 832

75+ 254 458 783 1,196 1,373

Total 8,024 7,265 7,498 7,688 7,709


Figure 4 illustrates a rapid rise in the percentage of the population over the age of 65 between 2001 and

2031 in the North Thompson LHA. In 2001 the population over 65 years of age was only 10%; however,

by 2031 this is anticipated to be 31% of the total population. In comparison, the Kamloops LHA will rise

from 12% in 2001 to 25% in 2031.



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Figure 4 North Thompson and Kamloops Local Health Area Population Shares by Age Categories (2001 to 2041)

North Thompson LHA

2001 2011 2021 2031 2041

Kamloops LHA


29%

61%

7% 3%

0‐19 20‐64 65‐74 75+

22%

61%

11%6%

0‐19 20‐64 65‐74 75+

18%

55%

16%

11%

0‐19 20‐64 65‐74 75+

18%

51%

15%

16%

0‐19 20‐64 65‐74 75+

19%

52%

11%

18%

0‐19 20‐64 65‐74 75+

26%

62%

7%

5%

0‐19 20‐64 65‐74 75+

21%

63%

9%7%

0‐19 20‐64 65‐74 75+

19%

59%

12%

10%

0‐19 20‐64 65‐74 75+

19%

56%

12%

13%

0‐19 20‐64 65‐74 75+

18%

57%

10%

15%

0‐19 20‐64 65‐74 75+



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3.1.6 Population Health

The median age of the population and median age of death of the population is shown in Figure 5 for

the North Thompson and the other eight LHAs in the IH service area. The North Thompson Valley LHA

falls approximately in the middle of both these indicators, with an average age of 48 and average age of

death of 66. There is considerable age of death variation among the LHAs, as much as 20 years. This is

likely due to demographic, health, social and economic conditions, but correlations are often unclear.

For example, Revelstoke has a low average age of death, yet has one of the highest socio‐economic

rankings in the region, whereas Salmon Arm has the highest average age of death, but has a socio‐

economic rank well below that of Revelstoke. Migration patterns and residency in proximity to health

services may be a factor in these averages.

Figure 5 Median Age & Median Age at Death by LHA, 2013

Source: Interior Health (2014b)

The standardized mortality ratio indicated in Figure 6 is the number of deaths occurring among North

Thompson residents compared to the expected number of deaths as derived from provincial age‐

specific mortality rates. A ratio of less than 1 indicates fewer deaths occurred than expected, while a

ratio greater than 1 indicates the opposite, that more deaths occurred than expected. Only 3 of the 19

causes exhibited rates below the provincial average. In some cases, notably traffic accidents and lung

disease, mortality rates greatly exceeded provincial averages.



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Figure 6 North Thompson Standardized Mortality Ratio, 2007‐2011


The chronic diseases displayed in Figure 7 represent health conditions affecting most communities in the

IH service area, including the North Thompson Valley. Instances of Chronic obstructive pulmonary

disease (COPD) are well above provincial levels, while depression and anxiety occurrences are well

below. Other diseases are in the range of the province and IH.

Factors that contribute to these diseases including smoking, alcohol abuse, high blood pressure, physical

inactivity, elevated cholesterol, poor diet, raised blood glucose and obesity.

Figure 7 Chronic Disease Crude Prevalence Rates, 2011‐2012

Source: Interior Health (2014b) Note: COPD Chronic obstructive pulmonary disease



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The alternative level of care (ALC) days presented in Figure 8 for the 2008 to 2013 period are the days a

patient spends in hospital after their acute care needs have been met. They remain in hospital because

alternative care options are not available. ALC Days are an important measure of the appropriate use of

acute care resources.

Although there is year to year variation in the data, it is clear that ALC Days among North Thompson

Valley residents exceeds IH and provincial use by a considerable margin, if not continuously then at least

on a regular basis. For the years 2008‐2009 and 2011‐2013, ALC Days among North Thompson Valley

residents was 60% greater than the IH average. This is placing considerable pressure on acute care

services, specifically at Dr. Helmcken Memorial and Royal Inland hospitals as this is where the majority

of patients are being placed.

Figure 8 Alternative Level of Care Days per 1,000 Population, 2008‐2013




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The mortality rates presented in Table 4 show steadily increasing standard mortality ratios, deaths and

cancer deaths in the NTV since 1991.

Table 4 Mortality Statistics, Selected Four Periods, 1991 to 2011

North Thompson LHA‐ 026

All Causes Cancer

SMR Death D<75 SMR Death D<75

2007‐2011 1.43 205 93 0.98 45 28

2002‐2006 1.19 143 79 1.30 47 32

1999‐2003 1.15 129 80 1.07 39 26

1997‐2001 1.13 128 79 1.06 36 24

1991‐1995 0.95 104 70 1 30 17

Kamloops LHA‐ 024

2007‐2011 1.13 4,276 1,840 1.07 1,221 676

2002‐2006 1.16 3,991 1,806 1.14 1,153 651

1999‐2003 1.05 3,699 1,715 1.09 1,028 608

1997‐2001 1.11 3,523 1,715 0.99 906 550

1991‐1995 0.86 4,830 2,014 0.89 1,356 763

Source: British Columbia Vital Statistics Agency (nda) (ndb)(ndc) (ndd), MHMRS (nd) Notes: SMR ‐ The ratio of the number of deaths occurring to residents of a geographic area (e.g., LHA) to the expected number of deaths in that area based on provincial age‐specific mortality rates. The SMR is a good measure for comparing mortality data that are based on a small number of cases or for readily comparing mortality data by geographical area.

Home and Community Care statistics for the NTV shown in Figure 9 indicate a sharp decline in residential, short stay and total beds between 2010/11 and 2012/13. As also shown, there are no assisted living units or beds in the local health area. Data in Table 5 indicate wide variations in some measures year to year. In 2011, there were 22 home care nursing clients, but this dropped to 11 in 2012 before rising to 16 in 2013. Home support clients and hours both rose during this same period, while residential care days dropped about 10%.



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Figure 9 Assisted Living, Residential, Short Stay Rates, 2010/11‐2012/13


Table 5 Home & Community Care QuickStats, 2011‐2013


3.2 HPEOLC SERVICES BY INTERIOR HEALTH

Hospice palliative care is one of the many Home and Community Care services offered by Interior

Health. Individuals must meet the eligibility criteria and be aged 19 or over, and may receive services in

a variety of settings according to their needs and stage of illness. Available services include registration

on the palliative Home Nursing Care program, access to the After‐Hours Telenursing Service for most

areas in IH, occupational and physical (rehabilitation) therapy, personal care and home support,

caregiver support and counselling, bereavement support, and spiritual care services as indicated. Home



21 | P a g e

and Community Care services are not insured under the Medical Services Plan, although the Province

does subsidize the cost of care.

For patients deemed palliative by a physician and who are receiving benefits through the BC Palliative

Care Benefits Program, there is no cost to receive home support for personal care. As for any patient

needing community nursing or community rehabilitation services, there is no charge for the services of a

Registered Nurse or therapist (Occupational and Physical Therapist). A daily per diem is charged for the

use of a publicly‐subsidized hospice bed and in cases of severe hardship, individuals may apply for a

waiver. Individuals and/or their families or physicians may request an assessment for Home and

Community Care services through Interior Health’s Home and Community Care offices. There are two

offices in the North Thompson Valley, one each in Barriere and Clearwater.

Table 6 Health Care Programs and Facilities in the North Thompson Valley

Facility Name Location Services Hospice Palliative

Services BedsTotal

Barriere Adult Day Program Barriere Adult day services ‐ 0

Barriere Health Centre Barriere Primary Health Care Laboratory services Mental health care

Caregiver support Home support

0

Blue River Health Centre Blue River Primary Health Care Caregiver support Home support

0

Clearwater Community Health

Clearwater Primary Health Care Caregiver support Home support

0

Clearwater Home Support Program

Clearwater Various health care and support services for residents with acute, chronic, palliative or rehabilitative care needs

Home support 0

Clearwater Mental Health Clearwater Mental health care ‐ 0

Dr. Helmcken Memorial Hospital

Clearwater Level 1 Community Hospital Surgical, inpatient and 24 hour emergency Laboratory outpatient services

Hospice care 6

Forest View Place Clearwater Residential care One bed for respite and one for End‐of‐Life Palliative care

21

Yellowhead Pioneer Residence

Barriere Supported living residence ‐ 10

Source: Interior Health (2014a); Easson 2015, pers. comm.

Patient referrals to Interior Health’s hospice and palliative care program may come from different sources

including acute care, the patient or a family member, the physician, or from residential care. For those in acute

care, many have cancer. The total number of clients with an open Home Care Nursing – End of Life

referral and at least one visit in the fiscal year in either the North Thompson LHA or Barriere Health Unit

was 29 in 2012/13 and 28 in 2013/14 (Interior Health 2015).



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3.2.1 Regional Palliative Care Teams

In the NTV, hospice palliative care is provided in people's homes through the Home and Community

Care program as described earlier. Individuals can access home support services (including personal

care), after hours telephone support, in‐home medication kit, and some supplies and equipment as

clinically needed. Hospice palliative care teams and volunteers are available for expert advice,

consultation and support to clients and their families, and to front‐line health care providers. These

services are accessed through IH’s Home and Community Care offices in Barriere and Clearwater.

Figure 10 Bassetlaw England Hospice Case Study

Overview

Situated in a peaceful location at the rear of the Retford Hospital, built in 1994 Bassetlaw Hospice provides specialised palliative care and support for patients, their families and carers for the community of Nottinghamshire, United Kingdom. Nottinghamshire has a population of 729,000.

History

Fundraising to build the hospice began in 1984 and early 1993, with almost $900,000 raised construction began. Daycare hospice facility opened to patients in December 1994 and in August 1997 a six bed private roomed inpatient

hospice unit was opened. In 2004 following discussions to secure hospice services for the future, it was decided that the charity would no longer receive full and regular operational health authority funding. The clinical costs would be met directly by the Bassetlaw Primary Care Trust, which has now been replaced by the Bassetlaw Health Partnership.

Purpose

The charity continues to be responsible for the operation costs of the building, maintenance, replacement and repairs. Every year the charity needs to raise $460,000 to continue the provision of specialist palliative care and support from Bassetlaw Hospice.

Overview of Services:

6 bed inpatient hospice unit 24hrs a day all year round.

Day Hospice facility and care program (serves approx. 60 patients per week).

Complimentary therapy services (i.e. reflexology, massage, aromatherapy).

Bereavement counselling services.Source: Bassetlaw Hospice (2015)

3.2.2 Residential Hospice Services

Hospice residences provide a home‐like setting and are often physically attached to a residential care

facility, hospital or other type of housing where hospice palliative care is provided on a 24‐hour basis.

A hospice residence is a place for people with a terminal illness in the last weeks of life (less than three

months in the IH region), who cannot stay at home and need help with their pain and other symptoms

and who do not require acute care. The hospice palliative care team, through discussions with the



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client, their family and physician, helps the patient or family make decisions about admission to a

hospice. Nursing staff work closely with specialized hospice palliative care physicians and volunteers to

provide care. Other team members such as clergy, social workers and pharmacists, provide consultation.

In the NTV, there is no specialized acute palliative care unit or dedicated hospice palliative care beds.

However, of the 21 beds at Forest View Place, two are swing beds including one for respite and one for

palliative care. Forest View has 24 hour nursing care in place. These swing beds have also been used to

provide overnight assistance to family members who are caring for family members at home when

home care nursing is not available. (Easson 2015, pers. comm.)

Generally, smaller communities in BC tend not to have dedicated hospice residences, even in health

areas that actively support hospice residences, such as Fraser Health. Fraser Health has indicated that

ten beds is the smallest size possible to provide efficient and effective staffing for a dedicated hospice

residence. They have several stand‐alone hospice residences serving a population of 1.6 million. They

accommodate HPEOLC patients in small communities through designated hospice beds, with modified

requirements, within an acute facility, such as is now done in the NTV. (Fraser Health Authority 2007)

Interior Health supports four stand‐alone residential hospices in Kamloops (Marjorie Willoughby

Snowden Memorial Hospice Home), Vernon (North Okanagan Hospice House), Kelowna (Central

Okanagan Hospice House) and Penticton (Moog and Friends Hospice House). Beds in acute care and

residential care facilities are also available for HPEOLC use.

3.2.3 Acute Care Palliative Services

Short‐stay beds are available on medical units in all Interior Health hospitals for hospice palliative care

patients needing diagnostic tests and treatment. Teams of health professionals specializing in hospice

palliative care provide expert advice, consultation and support about hospice palliative care to staff,

patients and families.

Specialized hospital units aim to comfort and support patients and their families who may be

experiencing difficulties managing pain syndromes, complex physical symptom assessment and

management issues, complex psychological/spiritual/social issues, family/caregiver distress or other

extensive or intensive care requirements. There are no dedicated tertiary hospice palliative care units in

the NTV, but when a resident needs admission to acute care for treatment of a life‐limiting illness, end‐

of‐life care or an unstable palliative condition, they may be provided service at Helmcken Hospital.

As seen in Figure 11, palliative care accounts for one of the highest case loads at Helmcken Hospital,

second only to convalescence during 2012/13.



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Figure 11 Top Ten Case Mixed Groups Based on Number of Cases Dr. Helmcken Memorial Hospital,

2012/13

Source: Interior Health (2013)

3.3 PHYSICIANS AND THE DELIVERY OF MEDICAL CARE TO HPEOLC PATIENTS IN THE NTV

3.3.1 Primary Care Physicians, General Practitioners and Nurse Practitioners

The North Thompson Valley has seven physicians with two family doctors based in Barriere and five

family doctors (with a husband‐wife team of physicians sharing one position for 4FTEs) in Clearwater.

There is also one doctor in Blue River based out of Mike Wiegele Heliskiing operation during the winter

season. All doctors in the North Thompson, except the doctor working out of Mike Wiegele’s, are

involved in palliative care as part of their family practices.

Home care nursing is available to visit people in their homes with three nursing positions in place to

assist people in the Clearwater area. Currently there is one full‐time permanent, one casual and one

vacant nursing position based out of Clearwater. In Barriere there are two full‐time permanent nurses

and one casual. Both Barriere and Clearwater have one nurse on shift during the day, six days a week

with the goal to increase this to seven days a week in the near future.

The Clearwater nurses will travel to Little Fort up to Vavenby to provide in‐home services and will travel

north as far as Blue River for first time assessments. In Blue River the nurse at the First‐Aid Post in Blue

River will also provide support for those that require nursing care. In Barriere the nurses cover the area



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south to McClure and out towards Agate Bay towards Adams Lake, they also cover the area up to and

including Little Fort. (Easson. 2015. pers. comm.)

The challenge with providing these services in the North Thompson is having them available when the

patient needs access to them. While there is home care nursing available, issues such as the patient

needing unscheduled pain relief cannot be predicted, and unlike a larger centre such as Kamloops where

there is always coverage, 24/7 coverage in the North Thompson is not available, which could pose

significant risks for patient care. (Soles. 2015. pers. comm.)

3.3.2 Specialist Palliative Care Physicians

Palliative patients and their primary caregivers need easy access to specialized consultation from

palliative experts (not necessarily in a crisis situation) so they can continue to manage the patient’s

changing needs. This consultation may occur by telephone and other electronic means. On occasion, it

may require palliative experts to become directly involved (BC Ministry of Health 2006).

In the NTV, the doctors support HPEOLC by making home visits, providing the appropriate referrals, and

supporting the care management process with other health care team members (Soles 2015, pers.

comm.).

3.3.3 Private HPEOLC Services in the NTV

The BCHPCA was invited to participate in Interior Health’s Palliative and End‐of‐Life Care Working

Group. This working group is a new organizational structure developed in response to the Ministry of

Health’s End‐of‐Life Care Action Plan. In the NTV it is believed that for‐profit home support is being

provided, but it is unclear what type of services and supports are involved as they are not often one‐

time purchases. However, it is known locally that a key to support is not necessarily about health care

services but support for non‐medical home support such as general household tasks and chores

including cutting fire wood, mowing lawns and shovelling of driveways (Easson 2015, pers. comm.).

3.4 LOCAL ATTITUDES TOWARD HEALTH SERVICES

In 2012, the University of Northern British Columbia’s Community Development Institute conducted a

community survey as part of the District of Clearwater’s Seniors’ Needs Project. Although the survey

only included Clearwater residents and dealt with a range of public health issues, some of the results

provide insights into HPEOLC issues.

According to the survey, 53% of Clearwater residents desire palliative care housing in the future. “Of

interest, however, there were also a number of respondents seeking higher levels of care through long‐

term or intermediate care facilities.” (Community Development Institute 2012)

The survey also asked respondents to identify the services people feel are needed to help older

residents maintain their health and wellness. Most of the services listed received high levels of support,

especially for home care, respite care, and nursing care while some respondents highlighted the need



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for a Nurse Practitioner in the community, more resident doctors, as well as more resources to expand

more routine and frequent access to home care, personal care, and other related health care supports.

Access to care networks is an important part of support for older residents. It can play a crucial role in

quality of life, how long seniors maintain their independence, and how long they remain in their own

homes. The presence of a support network may influence whether older residents decide to remain in a

community after they retire. While nearly all of the respondents identified that they had close friends

living in Clearwater, just over 60% had other family members in the community.

The survey illustrates some of the service gaps in the NTV when it comes to HPEOLC, specifically, that

while the quality of publicly‐funded health care is considered high, access to some services is limited,

while expectations are increasing for palliative care.

3.5 HOSPICE SOCIETIES IN THE NORTH THOMPSON VALLEY

There are three hospice societies in the North Thompson. In the southern portion of the North

Thompson and servicing Barriere and area is the Barriere and District Hospice Society (BDHS). The goal

of the Barriere and District Hospice Society is to find hope by sharing in an atmosphere of trust,

empathy, and confidentiality. Care is coordinated with patients, family and health care professionals to

provide support for those suffering from a loss, people who are terminally ill and their families (North

Thompson Volunteer and Information Centre 2015). The Society supports hospice care by:

Supporting patients living with life‐threatening illness;

Supporting family members whose loved ones face a life‐threatening illness (including

assistance with transportation);

Providing access to their library of books and videos;

Educating the community on death and loss issues;

Assisting those looking for hospice care in other areas;

Maintaining an equipment loan cupboard (contains items like wheelchairs, hospital beds, etc.);

and,

Supporting the seeking, screening and training of volunteers.

Working out of Clearwater is the Clearwater and District Hospice Society (CDHS) who, as a group of

volunteers, provides for personal care of terminally ill people and their families. The CDHS provides

similar services as the BDHS and has its goals to:

Maintain dignity, individuality and quality of life;

Provide physical, psychological or spiritual support where necessary (Soles 2015, per. comm.);

Maintain support at death and during bereavement;

Listen to and support the bereaved;



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Provide an atmosphere of trust, empathy and confidentiality where feelings and emotions can

be shared;

Increase awareness of the grief process that accompanies any loss experience; and,

Find new hope by sharing with others who are grieving, and so move from pain to healing (CDHS

2015).

The third hospice society in the North Thompson is the North Thompson Valley Hospice House Society

which is based out of Little Fort and became a registered non‐profit society in 2011. The NTVHHS is

working to develop the concept of hospice care in the North Thompson valley by raising money and

awareness around hospice care in the North Thompson Valley, and is dedicated to establishing a

residential hospice house in the North Thompson Valley. All members of the society board are volunteers

and their efforts over the years have lead to the raising of $30,000 through community fundraisers like

antique appraisal events and bike races (BC Ministry of Health 2015).



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Figure 12 Hospice North Hastings, Ontario

Overview

Hospice North Hastings (HNH) provides a special way of caring for patients facing end of life decisions. HNH is designed to improve a patient's quality of life and help alleviate the family's distress by providing efficient loving care, easing pain, and the overall emotional, spiritual, social and economic stress of the knowledge of impending death. The program's interdisciplinary team of professionals and volunteers work closely with the family during the illness, and through the bereavement period which could be up to a year. Centred in Bancroft, Hospice North Hastings services a rural population of approximately 13,000. History

North Hastings Palliative Support (original name) was started by two nurses in Bancroft in 1996. Hospice North Hastings began with the Home Visiting Program and now offers a Medical Equipment Loan Cupboard, a Lending Library, a Residential Hospice, R & R Caregiver Day Program and Bereavement/Grief Support. The Hospice House for North Hastings was the first “Rural” Residential Hospice in all of Ontario, providing 24/7 “end of life” care to individuals and families and has been operating continuously since 2005.

Hospice House Operations

At the home there are two “End of Life” rooms that are available for residents of North Hastings during their final days. In addition, there is a room for family members to stay at the house. The Hospice provides 24hr/7 day support coverage with a Personal Support Worker (PSW) being on shift over the night and the Program Coordinator being at the home during the day. The home is also supported by the Hospice’s volunteers who provide many of the services and support to the patient and the family. The patient also sees a community nurse, just as they would if they were in their own home. Overall, the program offered at the home is an alternative to hospital admission and the care is based on patient need. Families and caregivers are encouraged and welcome to participate in the life and care of the patient at the Hospice.

The Hospice is focused on clients with a palliative performance scale (PPS) of 30%, which means that they are within the last 2 to 3 weeks of life, have stopped taking solid food and are bed bound. This is important because many of the supporting volunteers are between the ages of 55 and 80 and not able to do bed transfers. The average stay is 8.8 days and the house looks after 10 to 25 clients in the house a year and is now in its ninth year of operation.

The Hospice is self‐funding and has actually turned away funding from the province of Ontario to ensure the mission of Hospice of North Hastings is the central priority of the house. This results in a lower ratio per capita than is typically forecast by health authorities as they do not try to fill their beds in order to secure health care funding from the province.

As such the Hospice undertakes formal fund raising activities and runs three businesses with the businesses including: two billboard signs, a events rental business, and film circuit (partner in North of 7 Film Fest). HNH focuses on getting locals to donate locally and operates several annual fundraising events including: The Hospice Gala, Memorial Doves (Christmas time), Autumn Colours Hike and more. HNH raises $200,000 annually of which $80,000 is used for hospice house operations.

Source: Hospice North Hastings (2015); and Minnie. 2015. pers. comm.



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Figure 13 Lumby Campus of Care Case Study

Partners in the District of Lumby have

been working towards the

development of a seniors campus of

care in downtown Lumby. The term

“campus of care” refers to a situation

where more than one level of housing

and care is provided in a residence or

group of buildings (BCMOH 2015). In

Lumby, the concept began with the

development of a centrally located

Saddle Mountain Place. Saddle

Mountain Place is made up of 40 units

which include 20 Bachelor Suites and 20 one bedroom suites. Tenants range in age from 55 to 90. The rent is very

affordable as the goal is to provide low cost housing for seniors. Each unit has a front door which opens into a long

hallway and a back door which opens to a small porch.

In 2010 work began on second phase of senior housing for Lumby which was named Monashee Place. These 16

units included a land donation from the Lumby and District Seniors Citizens Housing Society (LDSCHS),

development cost charges from the Village and $2.1 million from the Canada‐British Columbia Affordable Housing

Initiative. Monashee Place also encourages independent living for seniors living on a limited income and also for

people struggling with disabilities living on a fixed income. These additional sixteen units are managed by Lumby

and District Seniors Citizen Housing Society. This society also operates the 40 units at Saddle Mountain Place.

Opening in 2013, the Monashee Mews residential care facility is located beside the Saddle Mountain Place and

Monashee Place. This residential care facility cost $10 million to construct and has 46 residential care beds,

employing 42 employees. The facility is owned and operated by inSite with Interior Health contracting with inSite

for all 46 beds. Monashee Mews was built and decorated to be as home‐like as possible and is located in the heart

of the community. Programs are designed around the needs of specific resident populations, including a care

program for physically frail seniors, dementia care for seniors in the mild to moderate stages of dementia, and a

dedicated 10‐bed unit for adults with

acquired brain Injuries.

These three care facilities are connected by

sidewalks and paths separated by green

spaces and all have easy access to the

Lumby Health Centre clinic which is served

by the three family doctors in the

community and provides a number

preventative health programs as well as

access to X‐ray and lab services.

Source: LDSCS (2015) BCMOH (2015) IH (2013)



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4 NEEDS ASSESSMENT

The future need for HPEOLC services in the NTV have a direct bearing on the feasibility of a potential

hospice space in the Valley because capital and operating requirements would only be justifiable if there

is sufficient, predicted demand and if there is a relatively clear case for there being a gap in existing

services.

4.1 ESTIMATE OF DEMAND

Circumscribing demand is challenging because HPEOLC services are available through a continuum of

care delivered in a variety of physical settings. In the recent past, the nature, scope and place of care has

evolved in response to demographic change, advancements in technology, innovations in the principles

of practice and policy developments in the public health care system.

The key factors affecting HPEOLC demand in the NTV are as follows:

Between 2007 and 2011, the NTV registered 205 deaths, 45 of which were due to cancer.

Cancer deaths would increase in the future either as a function of population growth or if cancer

rates elevate due to the aging of the population, or both. Another consideration are needs

associated with non‐cancer patients. The demographics of terminal illnesses are shifting, and

the increasing levels of chronic diseases with less predictable trajectories than other terminal

diseases, such as many cancers, may result in more referrals or longer hospice stays due to more

effective screening and referrals. There will be a societal impetus to support more home and

residential care facility‐based deaths.

The total number of clients with an open Home Care Nursing – End of Life referral and at least

one visit in the fiscal year in either the North Thompson LHA or Barriere Health Unit was 29 in

2012/13 and 28 in 2013/14 (IH 2015).

An information request to Interior Health for an average length of stay for patients receiving

HPEOLC did not receive a response. The research reviewed for this study, and anecdotal

information provided by key informants, showed a wide range of experiences. In the North

Thompson Valley and the Interior Health region a range of between 10 and 20 days appears to

be the prevailing experience. An average stay at Margaret Willoughby Snowden Memorial

Hospice Home is believed to be approximately 13 days (Matthews 2015, per. comm.) Moog &

Friends Hospice House reports an average stay of around 17 days (Penticton and District

Hospice Society). Based on these data, it is estimated between 0.15 to 0.3 beds are required for

patients receiving HPEOLC.

There are no dedicated specialized acute or hospice palliative units in NTV and the majority of

resident deaths are occurring at Helmcken Memorial hospital or Forest View Place residential

care facility. Palliative cases are currently the second‐highest source of demand at the hospital



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(see Figure 11) and this could reasonably be expected to represent the highest case load in the

future as the population ages.

The future needs for HPEOLC in the NTV will be affected by the demographic trends described in

Chapter 3. The NTV population is not expected to grow significantly over the next 20 years so

increased demand from that vector is not anticipated. However, the proportion of the total

population accounted for by older age cohorts will rise, as will the median age. Demand for

HPEOLC services will therefore increase most likely as a result of the aging resident population.

As noted previously in Figure 4, the NTV’s 75+ population will be three times greater in 2041

than it was in 2011.

The Fraser Health Authority has determined that between 30% and 40% of all deaths should

occur in a hospice. In quantifying their bed requirements, they established a 45 day stay average

and factored up by 10% the number of cancer deaths to account for non‐cancer patients (Fraser

Health Authority 2007). Using these same coefficients, the estimated demand for hospice beds

in the NTV is presented in Table 7. It is recognized that projecting demand for hospice beds in

the North Thompson Valley using population projections, existing disease rates and existing

lengths of stay is simplistic but there is neither the data nor the modelling resources available to

this study to reduce uncertainties and increase levels of confidence about future expected

needs.

Table 7 Population and Hospice Bed Requirements in the North Thompson Valley, 2014 and 2024

2014 2024

Population 7,265 7,500

# of Cancer Deaths 9 9

Cancer Deaths +10% 10 10

Projected Number of Hospice Beds Needed

to Meet Demand

0.5 0.5

Notes: Figures based on calculation of hospice beds accommodating 40% of total HPEOLC caseload, with an average length of stay of 45 days

4.2 GAPS ASSESSMENT

The desire by NTVHHS to explore options for enhanced access to and quality of HPEOLC is based on the

belief that gaps in the current system exist and that residents could be offered a better quality of life

once they have been diagnosed with a life‐limiting illness. Residents do have access to palliative “beds”

at Helmcken Memorial Hospital and Forest View Place, or are being supported at their place of

residence by services available through the Home and Community Care Program. Palliative beds at the

hospital provide clients with clinical services for pain management, symptom control and comfort care

when individuals die. For residents of the North Thompson Valley, the physician, home care nurse and



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palliative care team will make referrals to Forest View Place or to another facility in the region if deemed

appropriate.

However, there are a number of other considerations that suggest better care outcomes could be

achieved. The Canadian Hospice Palliative Care Association advocates a comprehensive approach to care

based on the national principles and norms of practice that embrace the psycho‐social, spiritual,

bereavement and practical needs of clients and their families coping with life‐limiting illness (CHPCA

2013a). The guiding principles stress equal accessibility to HPEOLC for all individuals and families no

matter where they live and when they need it.

It was beyond the resources of this study to assess the quality and efficacy of the existing HPEOLC

services now being delivered in the NTV. Accreditation Canada’s last review of IH services (Accreditation

Canada 2013) did not identify any unusual issues with hospice palliative care and there was no mention

of services extended to the North Thompson Valley, but the report did note that in some communities

palliative care could be improved through better recruitment of clinical staff, focused teaching of patient

needs and the development of rooms that provide a better environment for patients and their families.

At the provincial level, the Provincial End‐of‐Life Care Action Plan has put an emphasis on redesigning

health services delivery, improving informational resources and exchange, and strengthening

accountability and efficiency—each of these has practical implications for the North Thompson where

the number of hospital deaths should be fewer than they are today, while improving quality of life for

patients and their families. This includes better and sooner diagnosis of those who could benefit from

hospice palliative care so they and their families can access services in a more timely manner.

Unfortunately, in the North Thompson the number of deaths is no longer tracked for the Helmcken

Hospital and Interior Health does not collect death statistics by location at the LHA level (Easson and

Osman, 2015). Therefore it will not be known if the of decreasing the number of hospital deaths in the

future will be achieved in the North Thompson. This will make it impossible to benchmark against the

provincial standards and goals in the future unless death reports at the LHA level become available.

The BCHPCA has noted that access to different types of HPEOLC services varies considerably across the

province, with home‐based palliative care, respite care, caregiver support groups/ clinics and advance

care planning much less widely available, a challenge that needs to be addressed. Moreover, financial

sustainability is a major concern of volunteer organizations providing services. The median operating

budget for hospices in the Fraser Health region (where most hospices are operated by the Health

Authority) was almost nine times the median for those in Interior Health (which were predominantly

volunteer societies) (BCHPCA 2014).

The 2012 survey of Clearwater residents about their future health care outcomes indicated the need for

a Nurse Practitioner in the community, , as well as additional resources to expand more routine and

frequent access to home care, personal care, and other related health care supports. Importantly,

access to care networks was an important part of support for older residents. It plays a crucial role in

quality of life, how long seniors maintain their independence, and how long they remain in their own



33 | P a g e

homes. Moreover, the presence of a support network may influence whether older residents decide to

remain in a community after they retire. (Community Development Institute 2012)

In addition, the community support network is an important element for residents whose health and

ability to remain in the community begin to decline. Simple day to day tasks such as assistance doing

housing cleaning, shoveling snow, cutting grass, grocery shopping and chopping firewood should not be

over looked, as this all becomes part of residents maintaining their independence and being able to stay

in their homes. The network of volunteers and service providers must reach beyond the services simply

provided on a medical front, but encompass the entire realm of independent living. This is particularly

important for residents who don’t have strong family ties in the community. However, even when the

patient has a spouse in the home, or family in the community, care demands often move beyond the

capacity to cope, and how the support systems in the community respond is critical.

Finally, at the end‐of‐life stage of support, it is critical to have the appropriate options to support the

family and the patient in the community. This involves a holistic team approach that is capable of

adapting as the needs of the patient change. While Clearwater does have access to respite beds that

provide flexibility to accommodate patients at the end‐of‐life and are used on an overnight basis to

provide family members who are providing care a break, unfortunately, in rural communities in the

North Thompson, patients are often transferred to the larger regional facilities in Kamloops for the care

they need. This can make end‐of‐life challenging as the patient is often separated from family and

friends who are unable to travel easily or have challenges with the considerable travel time and cost.

Ideally, the patient would be able to remain in their own home as long as they choose; however, once

additional care is needed, the person would have the option to utilize a hospice facility that provides the

quality environment and care needed to support a high quality of dying experience for the patient to

pass with dignity in peaceful and caring surroundings. Overall, the integrated goal and options would

allow the patient to remain in the community close to family and friends throughout the entire of end‐

of‐life process.



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5 FEASIBILITY ASSESSMENT

5.1 POTENTIAL DELIVERY MODELS

HPEOLC can be delivered in one of the following four settings:

The individual’s own private home or Assisted Living Residence with support from the local

Home Care Program;

Residential Care Facility in a long‐term care or short‐term community hospice or swing bed;

Hospice residence; or

Acute care hospital.

In the NTV there are beds used for hospice palliative care in acute care (Helmcken Memorial hospital)

and residential care (Forest View Place) facilities. The terms of reference for this report did not provide a

specific concept but asked for an description of potential models and recommendations for either a

licensed care facility or housing option as they would apply to the NTV. The challenge with developing a

concept is that the above‐noted models only account for one aspect of HPEOLC, that is the physical

space where services are delivered. They can be further developed by defining ownership and funding

arrangements, management and staffing regime, partnerships and target client characteristics, among

others. Importantly, the health care regulatory environment in BC is complex particularly in relation to

facility licensing, standards of care and use of or access to health care professionals, each of which

would affect how HPEOLC would, could, or must be provided. As illustrated in the case examples

provided in this report, the solution that seems to work in most communities is tailored to the specific

circumstances of the region being served.

5.2 DEMAND AND REGULATORY CONSIDERATIONS

The Needs Assessment in the previous chapter indicated that the hospice bed needs of the North

Thompson Valley today and for the foreseeable future would be in the order of one and at the very

most two beds. This might change if there was a decision to provide respite care or perhaps to

accommodate caregivers and family members as well. In any event, the size of the service area

population, and existing HPEOLC options (e.g. home care, acute care, residential care) sets clear

parameters for the potential scale of a dedicated space. In consideration of the fact that provincial

policy is to support the delivery of HPEOLC primarily in the patient’s home and in residential care

facilities, or in acute care hospitals for individuals with acute and complex conditions, and that in the

Interior Health region there are only four hospice residences (Marjorie Willoughby 12 beds, North

Okanagan Hospice House 12 beds, Central Okanagan Hospice House 24 beds, Moog & Friends 12 beds)

serving a population of approximately 726,000, the development of a new, stand‐alone licensed care

facility being paid for or managed by IH in the North Thompson Valley is not considered a feasible option

and thus will not be assessed in this report.



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5.3 DEFINING THE OPTIONS

There are three basic options for enhancing HPEOLC in the NTV, which are outlined in Table 8 and

discussed below. Each option is defined in terms of the six dimensions shown in Figure 14.

Figure 14 Dimensions of HPEOLC Services

Hospice Outreach – This option would offer psycho‐social and other support services, such as peer

counselling and short respite care, from trained volunteers to clients approaching the end‐of‐life and

their family caregivers. There would be no physical development or acquisition of hospice space or beds

to deliver in‐patient care. The focus would be on residents in the North Thompson Valley who have been

diagnosed with life‐limiting illness and their family members who could benefit from the hospice

outreach services available, which could also include bereavement and grief support. The palliative

client’s clinical care needs would be assessed, coordinated and met/overseen by a Home Care Nurse

from the Home and Community Care Program of Interior Health, and each client would have an

attending physician. This option would mean collaborating with the existing hospice societies in the NTV

to continue providing and possibly enhancing the support services available. This option would help

improve the access and quality of HPEOLC services in NTV, and could also support clients to remain in

their own homes longer and have a home‐based death if they so wished. By providing family members

and clients with additional support at the end‐of‐life, for example information and relief through peer

counseling, respite (to sleep or run errands), and even some meal provision, this option would offer a

hospice‐in‐the home, or virtual hospice.

Hospice, Palliative and

End‐of‐Life Care

Target

ClientsCare Model

Cost

Licensing

and Regulatory

Governance

and Access to Care

Partners



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Table 8 Comparison of Option Definition and Scope

Hospice Option Hospice Outreach Hospice House Enhanced Residential

Room

Target clients PPS per IH policy PPS per IH policy Clients in last 6

months of life deemed palliative by physician

Respite care Family and care‐

givers

PPS per IH policy Clients in last 6

months of life deemed palliative by physician

Care Model NTVHHS Supplemental home‐

based care

NTVHHS Alternative housing

care

NTVHHS Developing or

improving end‐of‐life care room

Care not provided Governance and Access to Care

NTVHHA relies on IH Home Care Nurse to refer client to NTVHS outreach

Self‐referrals Client must request

service

NTVHHA plans, funds, operates, maintains Hospice House and volunteer program

IH delivers HCN and palliative program and HSWs to clients as eligible and as if they are in their own homes

Clients self‐refer or referred by HCN or physician

NTVHHS negotiates with facility owner/operator and all access to room/bed is per standard IH and facility policy and procedures

NTVHSS would not influence access or use of room

Partners Clearwater and Barriere hospice societies

IH for referrals through Home and Community Care Program

Clearwater and Barriere hospice societies for operations

Interior Health for referrals through the Home and Community Care Program

Contract Service Provider or Interior Health

Licensing and Regulatory

None Not licensed as a care facility

Housing only

None

Costs < $30,000 annually Capital: $250,000‐$350,000 Operating: $120,000‐$160,000 annually

Capital: $50,000‐$150,000 Operating: ≥ $30,000 annually



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The costs of this option would be less than $30,000 annually, but this does not account for the

activities of the Clearwater and Barriere hospice societies. The NTVHHS has already raised this

amount of funding and it could continue to do so with expenditures targeted at advocacy, on‐

going fund raising, education and training and the purchase of palliative care equipment.

Hospice House – This option would be similar to the North Hastings House profiled in the

previous chapter. It would be a suitable stand‐alone house purchased, rented or donated,

offering a place for those needing respite, and/or end‐of‐life care to spend their final weeks or

days. The Hospice House would be part of the integrated team approach to patient care at end‐

of‐life with clients coming from anywhere in the NTV, and care duties would be coordinated and

shared by family, friends, trained volunteers and Home Support Workers authorized by the

client’s Home Care Nurse through Interior Health’s palliative care program. The home would be

easily accessed and have at least two bedrooms on the main floor suitable for bed‐ridden

patients. The necessary modifications would be made to accommodate tilting wheelchairs, by‐

pass steps, add overhead lifts and ensure proper bathing and toileting facilities for full‐assist

patients, and be suitable to accommodations family caregivers wishing to stay overnight.

This ‘hospice housing’ option would not be a licensed care facility with its own hired staff, but

rather would be an alternate housing option considered to be the client’s own home for the

duration of their stay. This option would only be able to support stable, non‐complex palliative

patients and assumes the palliative client’s clinical care needs would be assessed, coordinated

and met/overseen by the Home Care Nurse as if the patient was in his/her own home. Each

client would have their own attending physician who would liaise with the Home Care Nurse per

their usual process. This option would require Interior Health to view the hospice house as an

alternate form of housing and as such, would continue to allow the client to be eligible to

receive those same IH palliative services and benefits they would receive as if they remained in

their own home. Such a hospice house would not require to be licensed as a care facility under

British Columbia’s Community Care and Assisted Living Act providing it does not house and care

for more than two patients unrelated to each other at one time. It would be self‐funded.

The cost of this option, based on a review of real estate values in the region and the financial

statements of other similar hospice houses, would be in the range of $250,000 to $350,000 for

the purchase and improvements to an owned house and approximately $120,000 to $160,000

annually for operations. Capital would be required for property purchase, improvements,

furniture and equipment. However, some of these costs would be offset through donations and

volunteer work, for example by contractors and suppliers. Major operating cost items would be

household supplies, food, utilities, repair and maintenance, insurance, bank charges, and

education and training.



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Enhanced Residential Room ‐‐ This option would involve NTV fund‐raising to decorate, improve,

design or dedicate a room in an existing or planned acute, residential or assisted living facility in

NTV, for the purpose of improving the end‐of‐life care experience and satisfaction for the client

and his/her family care givers. The preferred facility would be either assisted living or residential

care, with the latter either privately owned/operated, or owned/operated by Interior Health, or

owned/operated by a third party and contracted to Interior Health. Regardless of ownership and

operator, NTVHS could not influence or decide admission policies and procedures for the room

and who could use (or not use) it. Costs would be driven by the size of the chosen project in

consultation with the facility owner. There would be no impact to licensing, staffing or care costs

for NTVHS or the facility providing the overall census of rooms is not changed.

The costs for this option could vary widely, depending on the condition of the facility for which

enhancements would be done and whether or not the project called for new/additional

improvements or simply an upgrade. The improvements could be to an existing room or

common area and may involve “decorating” or more substantial upgrade of the physical space.

The scope and scale would really depend on the facility and owner/operator who would be the

subject partner. An order or magnitude estimate for capital is between $50,000 ($50 per square

foot for two 500 square foot rooms) for improvements to $150,000 for an add‐on to an existing

or planned facility. There would be associated increased operating costs as well, and these

would depend on project scope and the structure of the agreement with the subject facility and

Interior Health as applicable. The following basic arrangements could be considered:

If the enhancement is made to an existing bed in an acute care hospital or residential care

facility then the ‘decorating’ and/or equipping/furnishing costs would largely be a one‐time

expenditure, since annualized operating costs would already be addressed and covered

through the standing agreement between the IH and the operator.

If the enhancement is an addition to a facility of one room paid for by NTVHHS, neither the

facility operator nor IH would simply assume the additional operating costs without first

coming to an agreement about what the increased costs would be and who would pay for

them, and when. New annualized operating costs would have to be discussed and

addressed before proceeding.

If the enhancement is to one room in a planned but not‐yet‐built facility and the overall

census of rooms/residents will not change with the proposed enhancement, and the

owner/operator has a signed contract with IH to provide a set number of rooms for a set

number of residents already, then the annualized operating costs will have already been

taken into account and presumably IH would not be asked by the owner/operator for more

annualized funding as a result of the planned enhancement.



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5.4 EVALUATING THE OPTIONS

The above‐three HPEOLC options available to the NTVHHS are clearly different not only in terms of their

governance, care models and cost structures, but also in the way they would meet expectations for

improving the quality of life for those residents of the North Thompson Valley dealing with the end‐of‐

life. Each option provides different approaches and services which can be compared to determine how

best to allocate resources in support of improving HPEOLC for residents.

The issue of resource availability is an important one that this assessment must consider. The CHPCA

model for guiding organization development and function is a conceptual framework that “squares”

activities, functions and resources (CHPCA 2013a). Hospice palliative care organizations are encouraged

to apply strategic planning principles from mission and value statements down to business plans in

determining how they choose to build up their infrastructure. Figure 15 shows the relationship between

the different aspects of hospice palliative care and central role that resource availability plays, whether

it be financial, human, physical, community or information‐related.

An evaluation of the options, therefore, must be framed in the context of NTVHHS and its strategic

direction and access to resources. These parameters become important guideposts for evaluating the

relative merits of the options.

Figure 15 The Square of Care and Organizations

Source: CHPCA (2013a)

In order to help evaluate the options, the following criteria were developed based on a review of the

CHPCA framework and how it could be applied in this study:

Cost – cash and contributed equity that is required to keep the option as a going concern



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Ease of implementation – a composite measure of the business, financial, regulatory and

community requirements of implementation

Risk and uncertainty ‐ the potential for unpredictable or unintended outcomes, and the

mitigation measures available to control these

Local control – the extent to which the local community is involved in the provision of care and

improving outcomes for residents

Community support – the extent to which local government, community groups and the public

provide support, for example through reduction of red tape, donations, fundraising and

partnerships

Volunteer support – the extent to which individuals in the community are likely to be involved

as client, auxiliary, fund‐raising or co‐facilitation volunteers

Quality of care – potential for improving stated provincial and IH hospice palliative outcomes in

the NTV

Figure 16Figure 16 provides an overview of the advantages and disadvantages for the three options

based on a consideration of these criteria. The evaluation is relative and in some part subjective based

on evidence drawn from the literature review.

Figure 16 Pros and Cons of the Three Major Options



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Maintaining a virtual hospice through the Hospice Outreach option has the advantage of being relatively low cost,

low risk and easy to implement. There are no major capital costs to support (although a peer‐education program

would be required to train volunteers in advance care planning, bereavement support and possibly delivery of

basic care), demands on volunteers would be marginal and the Society could continue to work toward improving

HPEOLC outcomes by improving opportunities for residents to die at home if they so choose. This could be

accomplished by targeting service gaps, especially those involving non‐clinical services that ease the burden on

family and caregivers. Expanding the equipment cupboard, promoting education and advance care planning,

assisting care teams sourcing hospice beds and providing supplemental home support could all be improved in the

NTV.

The disadvantages of this option is that it does not deliver on the stated aim of the NTVHHS, that is the

provision of in‐patient hospice palliative and end‐of‐life care (HPEOLC) licensed care facility or housing

option with care services for residents of the NTV. The impetus for the Society was the investigation of

the physical development of incremental hospice palliative beds. If the research indicates this is not

feasible at this time, then a decision must be made concerning its future role, specifically in relation to

the potential for overlap with the other hospice societies in Barriere and Clearwater. There is a strong

case to be made for a valley‐wide approach to HPEOLC that Barriere and Clearwater by themselves

cannot resolve by working only within their communities. But it is also true that a coordinated regional

approach can be achieved if the two societies conduct more joint planning and engage in the sharing of

resources and services with a view to valley‐wide mandate of care. In either case, community and

volunteer support is likely to be less when compared to the other options. This would be attributable in

part to absence of a physical space that the region can identify with, but also to the simple fact that the

intervention measures and costs are fewer, so there is less urgency for seeking out community support.

Finally, and notwithstanding the primary objective of optimizing in‐home HPEOLC, this option does not

address the absence of dedicated hospice palliative beds in the region.

The Hospice House option is one of two that delivers on the NTVHHS mandate for a licensed care facility

or housing option. It directly addresses the housing gap that exists between in‐home care and the

existing licensed acute care and residential care facilities in Clearwater. The case examples in this report

indicate that when a hospice house is developed it can galvanize community and volunteer support. It is

more likely to attract donations, fundraising support and in‐kind contributions of labour, goods,

equipment and furnishings than either of the other two options. It becomes a community asset, with a

physical street presence that residents can see is an enhancement to existing hospice palliative care

services. This option results in the best outcome for HPEOLC as it provides those with a life‐limiting

illness who do not require acute care to remain in the Valley in a dedicated hospice bed.

The drawbacks of creating a hospice house are its costs not only in absolute terms, but also in relation to

the fundraising and donor capacity of the region. The population of the North Thompson Valley is only

7,300 and while raising the capital for the purchase and renovation or construction of the house is

possible if not likely, the need for ongoing operating funds, estimated at upwards of $160,000 annually,

would be challenging to maintain for such a small service area. Because it would not be a licensed care

facility it would not receive operating funds from IH nor be eligible for gaming revenues. It would have

to rely on donations, fundraising, grants and potentially fees.



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This option would be the most complex of the three to implement. While it would not be a licensed care

facility there are still a considerable number of permitting and logistical hurdles associated with

construction that the other two options would not face. The business planning and operational demands

are also much higher as this is the only option with full‐time paid management and staff. The capacity

and capability of volunteers and workers staffing the house would also need to be sufficient to ensure

the patients receive the standard and quality of care expected and required.

For these reasons the Hospice House option carries the most risk, and though some of that could be

managed with proper planning and training of volunteers and staff, other aspects such as base, ongoing

operating costs would have to be absorbed in any case. Operations could be scheduled to commence

only when there was adequate working capital to deal with unanticipated contingencies, and services

could be scaled to avoid low levels of capacity utilization (i.e. unused bed space). As a social enterprise,

the Society could engage in complementary business activities that provide additional revenue sources,

for example through the operation of a thrift store or equipment rental business. Real property

represented by land and buildings would retain if not exceed their book cost over time so in a worst case

scenario marketable assets of the Society could be liquidated and still allow HPEOLC services to be

delivered.

The Enhanced Residential Room option is a moderate cost option, less than developing a hospice house

but actual expenditures would depend on the facility for which a partnership was developed. It is also

relatively easy to implement because it involves establishing a partnership with an existing or potential

licensed care facility, so there is no direct relationship with IH, at least in terms of care provision at the

facility providing the bed census remains the same. Although it would not have the same impact as a

hospice house, this option would still receive good community and volunteer support because it

involves new or improved HPEOLC space that is not just a swing bed in a residential care facility or the

hospital.

The only drawback of this option is that there is no opportunity to influence any aspect of admission or

operations, which would be the exclusive domain of IH and, potentially, the contracted service provider.

The other issue with this option is that it would almost assuredly be in Clearwater so there would be

some uncertainty as to support from other parts of the Valley, particularly Barriere where there is

already a hospice society delivering HPEOLC services, and where there is equally good access to facilities

in Kamloops. Unless there was a strong partnership arranged between all three societies, it would be

difficult to presume that Valley‐wide support would be automatic.

5.5 EXPLORATION OF SUB‐OPTIONS

All three options discussed above are feasible in the sense that they have been implemented in rural

communities elsewhere in BC or Canada. Each could be implemented in the NTV given the appropriate

partnership and fundraising capacity, and each would deliver improved HPEOLC services to residents of

the Valley. A preferred option would therefore depend on the values and expectations of the NTVHHS

and how they are affected or met in weighing the costs and potential benefits of each.



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From a strictly organizational perspective the Hospice Outreach option would not be a preferred choice

because it does not deliver on NTVHHS’s primary purpose of developing a licensed care facility or

hospice house. It is presented in this assessment as an option because virtual services that do not entail

a new physical space can still improve on care outcomes. But the virtual hospice model is also something

that the Clearwater and Barriere hospice societies could readily deliver on their own given that they

already serve the large majority of the population in the Valley. A strong case can be made that a third

organization delivering similar services would not create added value in terms of HPEOLC and should

therefore not be pursued.

In order to assist with identifying a preferred option, Figure 17 presents five sub‐options that have been

identified through the course of study. These include three hospice house options and two enhanced

acute/residential room options. Each of the five sub‐options are described in greater detail below.

Figure 17 Hospice House and Residential Room Sub‐options in the NTV

5.5.1 Purchased Independent Stand Alone Hospice House in Clearwater

Under this scenario, the North Thompson Hospice House Society and the Clearwater Hospice Society

would lead the development that would allow residents of the North Thompson the option to access a

local hospice house. This would involve the purchase of an existing home that could be custom fitted to

accommodate the hospice patients. The home would be in Clearwater and be within close proximity to

the health care providers based out of the Helmcken Hospital and Health Care Centre. This by extension

Hospice House

LeasedOwned

Clearwater Little Fort

Enhanced Residential Room

Existing acute care or residential care acility

New assisted living or residential care facility



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would also place it within close travel proximity to the home support workers based in Clearwater and

provided by Interior Health for the Clearwater area.

Given the unlikelihood of Interior Health providing operating expenses to a stand‐alone hospice with

relatively low demand, the home would need to rely on volunteers and their own on‐site coordinator.

To ensure residents receive the proper care required, this model would need to consider a home

supported housing option with nurses, doctors and home support workers visiting their patients in the

hospice house in the same manner as if their patient was in their own home.

The model would be similar to that established by North Hastings Hospice House in Ontario. Given that

the house would be relying on volunteers, the home would focus on patients who are at the final stage

of end‐of‐life care with a PPS of 30% or less, who may have stopped taking solid foods and are bed

bound. If patients are admitted that need to be frequently moved and fed then they would likely need

to be assessed as eligible to receive a full time 24/7 Home Support Worker.

Ideally, the hospice house would have a minimum of three bedrooms with two designed and suited for

hospice patients while the third bedroom would be suitable for family members who would like to stay

overnight with their loved ones in the house. The model for this option also would include space in the

house for an office and storage space to support the Clearwater Hospice Society volunteer work that

already operates in the Clearwater area and provides support services and access to equipment. Having

a related activity in the house could also help with the sustainability of the financial model.

Given the independent nature of the hospice house, the North Thompson Hospice House Society and

their partners would need to operate an active fund raising program in order to raise the money to

purchase and operate the house. The raising of funds might include $250,000 to $350,000 for the

purchase and renovation of the house and approximately $120,000 to $160,000 a year for operations.

5.5.2 Purchased Independent Stand Alone Hospice House in Little Fort

This scenario would be similar to the independent stand‐alone hospice house in Clearwater, only located

in Little Fort and would include the participation of the North Thompson Hospice House Society,

Clearwater Hospice Society, and the Barriere Hospice Society. This option would involve the purchase of

an existing home that would be suitable for hospice care in Little Fort. Little Fort is located 30

kilometres from Clearwater and 31 kilometres from Barriere, and is the only community in the North

Thompson Valley that is served by Interior Health home support workers in both Barriere and

Clearwater.

This would provide Little Fort with a larger pool of home support workers; however, unlike the

Clearwater scenario, each visit would require a 40 minute round trip drive by the home support workers

and a majority of volunteers. This travel would also make it more difficult for doctors to visit with

palliative clients as regularly as may be possible in Clearwater. All other elements of the house would be

the same as that described for the hospice house in Clearwater.



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5.5.3 Rented Independent Stand Alone Hospice House in Clearwater or Little Fort

Alternatively with the relatively large availability of housing stock for sale in Clearwater and Little Fort, it

may also be possible to enter into a long term rental agreement for a house; thereby, reducing the

capital cost required with the purchase of a house. In this scenario, the North Thompson Hospice House

Society could eliminate the capital cost of purchasing a house and focus on securing funding to support

the operations. However, in discussions with other rural hospice societies the purchase of the house was

followed by some of their larger legacy donations as people put funding towards the specific housing

purchase.

5.5.4 Enhanced Residential or Acute Care Room

In an effort to create a more desirable space that could focus on the needs of hospice patients, the

North Thompson Hospice Society would work with Interior Health to develop an extension to the

existing residential care home Foster View Place. This one story facility built in 2002, has 19 permanent

residential beds and 2 beds for palliative and respite clients. Rooms are private with views of the

gardens and surrounding forest. A dining room and activity area look out over a large covered ground

deck at the entrance of the garden. The Dr. Helmcken Memorial Hospital is adjacent for ease of access

to other health services. (Interior Health. 2015b)

The large size of the facility and the variety of patients in the Foster View Place does not provide an

optimal environment for those patients, their caregivers and families seeking end of life care. A similar

issue would be associated with a stay in the hospital, a fact that was meant to be explicitly addressed in

the government’s framework and End‐of‐Life Care Action plan. However, it may be possible to develop a

segregated space within either of these facilities, preferably semi‐detached from the main building, with

its own private entrance, which would create a more home‐like feeling. A major benefit of this sub

option is its close proximity to properly trained and available palliative care practitioners.

In this option, Interior Health would take a lead role and operate the extension as part of the normal

operating activities. Given that it likely will not fit with the future vision for hospice space by Interior

Health there will still be a requirement to undertake local fund raising to build the addition. This would

likely cost in a similar range as the stand alone home which would be $50,000 to $150,000; however, it

would not require the on‐going fund rising to secure operation funds.

5.5.5 Enhanced Residential Room (New Facility within Campus of Care)

The District of Clearwater is in the process of exploring the development of a Campus of Care in which

more than one level of housing and care is provided in a residence or group of buildings. While this

scenario is similar to extension of the foster view place to better accommodate hospice beds the

primary distinction would be to see patients drawn from a larger area than just the North Thompson

Valley in an effort to attract the numbers required making the operation of larger facility viable.

The hospice component would likely be a part of a residential care complex along the lines of the

Monashee Mews in Lumby that was developed by Interior Health and owned and operated by private

contractor, inSite. This facility has 46 beds with programs specifically designed around the needs of



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specific resident populations. The facility is structured to accommodate patients from a wider region

than just the local Lumby area to ensure the appropriate scale to ensure efficiencies. The total

construction cost of Monashee Mews was $10 million and currently employs 42 employees.

Adding in these additional rooms during construction of a new assisted living facility would cost

approximately $50,000 for two additional rooms.



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6 CONCLUSIONS AND RECOMMENDATIONS

6.1 CONCLUSIONS

The international and national context has evolved rapidly since the 1960s when St.

Christopher’s Hospice in the UK was at the forefront of the modern hospice movement. In

Canada, there has been considerable advancement in hospice palliative care standards and care

since 2002 when the Government of Canada released its Canadian Strategy on Palliative and

End‐of‐Life Care. In British Columbia, the Provincial Framework for End‐of‐Life Care (2006) and

its companion the Provincial End‐of‐Life Care Action Plan (2013) outline the pathway for quality

hospice, palliative and end‐of‐life care. In the 2013 Throne Speech, the Government of BC

promised to double the number of hospice, palliative and end‐of‐life care beds in the province

by 2020 (Province of BC 2013).

In terms of standards and norms of practice, the Canadian Hospice Palliative Care Association

has been at the forefront with a framework to guide hospice palliative care organizations.

The population of the NTV is approximately 7,300 and is projected to grow only marginally over

the next 25 years. However, the average age will increase—the 75+ population will be three

times greater in 2041 than it was in 2011. Increasing levels of progressive chronic diseases other

than cancer and more effective screening and referrals may also increase the need for services.

Even without an increase in population, there will be steadily increasing demand for hospice,

palliative and end‐of‐life care services in the Valley.

Using standard measures and coefficients from BC health authorities, it is estimated that

between 0.65 to 1.2 beds are required for patients receiving HPEOLC in the NTV. At this time,

there are no dedicated palliative units in NTV but there are swing beds available at Helmcken

Memorial Hospital and Forest View Place, both in Clearwater. The majority of resident deaths

are occurring at home, Helmcken Memorial Hospital, Forest View Place, or outside the region in

other facilities. Enquiries with IH and the Ministry of Health as to the historical distribution of

deaths were not answered. However, it is noted that palliative cases are currently the second‐

highest source of demand at the hospital.

Discussions with local stakeholders, including members of the Barriere and Clearwater hospice

societies indicate that there are gaps in HPEOLC services in the NTV. While it is believed IH

service goals are being met today, the data suggest that education and outreach, advocacy and

patient/family care could improve through more coordinated, integrated delivery and the

development of additional infrastructure.

North Thompson stakeholders also would like to see a more suitable hospice facility that

supports those at end‐of‐life in rural areas that is available in the larger urban centres in the IH

region. This is an important element in allowing family and friends to regularly contact and care



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for patients in a setting that supports option of dying with dignity in less institutionalized

settings.

Hospice palliative care is a philosophy of care that can be delivered in a variety of settings,

preferably at the client’s home but if needed in a residential care facility or a hospice residence.

These two options are the subject of this feasibility assessment but for reasons explained in the

report, a third option, hospice outreach is also evaluated. One option that is not considered is a

new, dedicated licensed care facility like those that exist elsewhere in the IH service area, for

example Marjorie Willoughby Snowden Hospice House in Kamloops. This model would not be

considered viable given the population and demand dynamics of the NTV and provincial policy

on the development of hospice palliative care infrastructure.

Each of the three options has its advantages and disadvantages and all would be considered

feasible given the right preconditions, most of which could be achieved in the NTV. The Hospice

Outreach option has the main advantage of being relatively low cost and easy to implement, but

it is does not meet NTVHHS’s objective of developing physical space and could be delivered by

the existing two hospice societies in Barriere and Clearwater. It therefore, represents a

throwback or contingent option if the other two cannot be implemented.

The Hospice House and Enhanced Residential Room would both meet NTVHHS’s objectives. The

former would bear the highest costs and risk and be challenging to implement, notably in terms

of fundraising, but it could be done based on the experiences of rural hospice houses elsewhere

in Canada. Enhancing a residential room (either existing or planned) has the strong appeal of

being lower cost and risk than a separate hospice house and would not bear the burden of

having to annually fundraise to meet operating costs.

The house and room options can be further divided into a number of sub‐options, including

leased or owned hospice houses in Clearwater or Little Fort, and enhanced rooms at existing

facilities in Clearwater and Barriere, or, as additions or upgrades to facilities that may be

developed in the future, for example, as a part of a new assisting living facility in Clearwater as

part of the goal of growing the campus of care model.

In conclusion, this assessment did not identify one superior option, but instead several options

that may be preferred or not depending on the organizational goals of the NTVHHS, access to

human, capital, community and partnership resources, and opportunities made available by

ongoing events and developments in the health care space. The options are not necessarily

mutually exclusive or static, and would likely evolve over time, again depending on the needs of

the community. This notwithstanding, the consulting team is of the opinion that in consideration

of NTVHHS’s capacity, community capacity, logistical issues and risk, the enhanced room option

would be favoured over either the hospice house or status quo.



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6.2 RECOMMENDATIONS

Meet with key stakeholders in the NTV to help identify a preferred option and next steps:

Host a joint planning session with Barriere and Clearwater hospice societies for a

coordinated approach to next steps and their roles in this initiative.

Meet with members of the Simpcw First Nation to determine how the service delivery

options might support their community and citizens.

Meet with IH and health care providers to determine their perspective and plans for

improving HPEOLC in the NTV. At this time, there is very little understanding for how IH

intends to meet its commitment to double the number of hospice palliative care beds in the

region and whether the NTV would be a target for future expansion of infrastructure.

Identify “champions” in the community and government who could provide support to this

initiative. There would have to be explicit and active backing of local government, local

health care providers, the other hospice societies and at least some IH staff in order to move

forward on any of the options.

Develop a long term strategic direction for NTVHHS. If any of the hospice options identified in

this report is to be pursued, NTVHHS will have to articulate how it intends to evolve as an

organization so there is a clear pathway for implementation. It will be challenging to gain

traction and obtain the commitment of partners without stating the vision, values, mandate and

purpose going forward. The plan would particularly want to address how the organization

differs from the other hospice societies, for example by answering the following questions:

Is NTVHHS a single‐issue organization, that is, the development of a hospice house in the

NTV?

Is it primarily interested in pre‐development planning (i.e. the exploration and study of

options), development (i.e. construction or placement of infrastructure), delivery, or

perhaps a combination of the above?

If the intent is to be involved in delivery, are there redundancies with the existing hospice

societies?

If the intent is to pre‐plan or develop only, what is the strategy for hand‐off to partner

organizations? And if a house or add‐on developed would the organization wind up?

Might NTVHHS adopt a specialized role that complements rather than overlaps with the

services of the other hospice societies? For example, could it focus specifically on pre‐

planning, development and after that ongoing fund‐raising, leaving the delivery of services

to the existing societies?

Is its future role or vision contingent on the option eventually pursued? For example, would

the development of a hospice house presume NTVHHS’s participation in ongoing

operations. Would the development of an enhanced residential or acute care room presume



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the opposite, that once developed NTVHHS would not be adding value to the services

already delivered by the other hospice societies?

The plan itself would have a long term mission, vision, goals and strategies, with specific

attention to how infrastructure and services are to be expanded. This aspect of the plan is very

important and would clarify the relationships among all the local hospice societies. The plan

would also have a fundraising component, including an objective evaluation of the region’s

financial potential.

Continue to qualify and update options.

Identify existing care facilities who could be partners for the co‐location of an enhanced

hospice bed.

Investigate opportunities for incremental revenue centres, such as a thrift store, rental

outlet, and annual marquee fund raising event(s).

Monitor developments with the Clearwater campus of care and the potential for new

facilities.

Set a timeframe and decision process for arriving at a preferred option. The latter would

include establishing criteria for a final evaluation using the framework provided in Section

6.4 of this report.



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7 REFERENCES

7.1 LITERATURE CITED

Accreditation Canada. 2013. Accreditation Report Interior Health Authority On‐site survey dates: September 23, 2012 ‐ September 28, 2012 Accredited by ISQua. Available at: http://www.interiorhealth.ca/AboutUs/QualityCare/Documents/AccreditationReport2012.pdf. Accessed: April 1, 2015.

Bassetlaw Hospice. 2015. Bassetlaw Hospice. Available at: http://www.bassetlawhospice.org/. Accessed January 27, 2015.

BC Government. 2010. Affordable Senior’s Housing Underway in Lumby‐ News Release http://www2.news.gov.bc.ca/news_releases_2009‐2013/2010HSD0058‐000699.htm

BC Hospice Palliative Care Association (BCHPCA). 2014. Hospice Palliative Care Services Survey 2013. Vancouver, BC. Available at: http://bchpca.org/wp‐content/uploads/BCHPCA‐HPC‐Survey‐2013.pdf Accessed: November 2014.

BC Ministry of Health. 2006. A Provincial Framework for End‐of‐Life Care. Victoria, BC.

BC Ministry of Health. 2013. The Provincial End‐of‐Life Care Action Plan for British Columbia. Victoria, BC.

BC Ministry of Health. 2014. End‐of‐Life Care. Available at: http://www2.gov.bc.ca/gov/topic.page?id=CC1FF2DFADD34BEC85869ECBA40A27AA Accessed: November 2014.

BC Ministry of Health. 2015. News Release: $40,000 to support North Thompson Valley Hospice House Society. May 17, 2014. Available at: http://www.newsroom.gov.bc.ca/2014/05/40000‐to‐support‐north‐thompson‐valley‐hospice‐house‐society.html. Accessed January 27, 2015.

BC Ministry of Health (BCMOH). 2015. Assisted Living Registrar ‐ Glossary of Terms. Available at: http://www.health.gov.bc.ca/assisted/glossary.html. Accessed January 22, 2015.

British Columbia Vital Statistics Agency. Nda. Selected Vital Statistics and Health Status Indicators – Annual Report 2011. Available at: https://www.vs.gov.bc.ca/stats/annual/. Accessed February 26, 2015.

British Columbia Vital Statistics Agency. Ndb. Selected Vital Statistics and Health Status Indicators – Annual Report 2010. Available at: https://www.vs.gov.bc.ca/stats/annual/. Accessed February 26, 2015.

British Columbia Vital Statistics Agency. Ndc. Selected Vital Statistics and Health Status Indicators – Annual Report 2003. Available at: https://www.vs.gov.bc.ca/stats/annual/. Accessed February 26, 2015.

British Columbia Vital Statistics Agency. Ndd. Selected Vital Statistics and Health Status Indicators – Annual Report 2001. Available at: https://www.vs.gov.bc.ca/stats/annual/. Accessed February 26, 2015.

BC Ministry of Health and Ministry Responsible for Seniors (MHMRS).nd. Selected Vital Statistics and Health Status Indicators – Annual Report 1995.



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BC Stats. 2014. Population Projections (1986 to 2041) for LHA 24, 26 and BC. Available at: http://www.bcstats.gov.bc.ca/StatisticsBySubject/Demography/PopulationProjections.aspx. Accessed November 17, 2014.

Canada Senate. 2009. Canada’s Aging Population: Seizing the Opportunity. Special Senate Committee on Aging Final Report. The Honourable Sharon Carstairs, P.C., Chair. The Honourable Wilbert Joseph Keon, Deputy Chair. Ottawa, Ontario.

Canadian Hospice Palliative Care Association (CHPCA). 2002. A Model to Guide Hospice Palliative Care. Available at: http://www.chpca.net/media/7422/a‐model‐to‐guide‐hospice‐palliative‐care‐2002‐urlupdate‐august2005.pdf Accessed: January 17, 2015

CHPCA. 2009. Caring for Canadians at End of Life A Strategic Plan for Hospice, Palliative and End‐of‐Life Care in Canada to 2015.

CHPCA. 2013a. A Model to Guide Hospice Palliative Care:Based on National Principles and Norms of Practice Revised and Condensed Edition: 2013.

CHPCA. 2013b. Fact Sheet: Hospice Palliative Care in Canada.

Canadian Institute for Health Information. 2008. Health Care Use at the End of Life in British Columbia. Ottawa, Ont.

Clearwater and District Hospice Society (CDHS). 2015. Who is Clearwater Hospice. Available at: http://www.clearwaterhospicesociety.ca/index.php?id=26. Accessed January 27, 2015.

Community Development Institute. 2012. District of Clearwater Seniors’ Needs Final Survey Report. University of Northern British Columbia, May 2012.

Fraser Health Authority. 2007. Fraser Health Hospice Residences Creating a healing & caring environment at the end of life Standards and guidelines for planning, development and operations.

Fraser Health Authority. 2015. Hospice Residences. Available at: http://www.fraserhealth.ca/your‐care/hospice‐palliative‐care/hospice‐residences/#faqItem23257‐4. Accessed: April 1, 2015.

Gold Standards Framework Centre.2015. About Us. Available at: http://www.goldstandardsframework.org.uk/ Accessed: January 17, 2015.

Government of BC. 2015. Home and Community Care – Policy Manual. Available at: http://www2.gov.bc.ca/gov/topic.page?id=8F569BDA913540DCAB75145DBB6070CE Accessed: January 14, 2015.

Health Canada. 2007. Canadian Strategy on Palliative and End‐of‐Life Care: Final Report. Ottawa, Ont. Available at: http://www.hc‐sc.gc.ca/hcs‐sss/pubs/palliat/2007‐soin_fin‐end_life/index‐eng.php Accessed: November 2014.

Hospice North Hastings. 2015. Hospice North Hasting Welcome. Available at: http://www.hospicenorthhastings.com/index.php. Accessed March 4, 2015.

Interior Health. 2013. Dr. Helmcken Memorial Hospital Facility Profile. November 2013.

Interior Health (IH). 2014a. Hospice Residences. Available at: https://www.interiorhealth.ca/FindUs/_layouts/FindUs/By.aspx?type=Location Accessed: November 2014.

Interior Health. 2014b. Local Health Area Profile North Thompson.



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Interior Health. 2015a. Home Care Nursing – End of Life Clients in the North Thompson Local Health Authority or Barriere Health Unit. Response to data request dated March 10, 2015. Data source: IH Data Warehouse, HCC Universe. Provided by Faye Jones, Strategic Information Analyst.

Interior Health. 2015b. Forest View Place. Available at: http://www.interiorhealth.ca/FindUs/_layouts/FindUs/service.aspx?svcloc=Forest%20View%20Place. Accessed April 22, 2015.

Lumby and District Seniors Citizens Society (LDSCS). 2015. Saddle Mountain Place. Available at: http://www.saddlemountainplace.ca/. Accessed January 22, 2015.

North Thompson Volunteer and Information Centre. Barriere and District Hospice Society. Available at: 2015. http://www.norththompsonvolunteer.com/node/8. Accessed January 26, 2015.

National Hospice and Palliative Care Organization (NHPCO). 2014. Facts and Figures on Hospice Care.

NTValley.com. 2014. Communities of the North Thompson Valley. Available at: http://www.ntvalley.com/valley‐map.htm Accessed: November 2014.

Penticton and District Hospice Society. 2015. Moog & Friends – About Us. Available at: http://www.pentictonhospice.com/about‐us.html. Accessed: April 17, 2015.

Pesut, Barbara, Barbara McLeod, Rachelle Hole and Miranda Dalhuisen. 2012. “Rural Nursing and Quality End‐of‐Life Care Palliative Care...Palliative Approach...or Somewhere in‐Between?”. Advances in Nursing Science. Vol. 35, No. 4, pp. 288‐304.

Province of British Columbia. 2013. Speech from the Throne The Honourable Judith Guichon, OBC Lieutenant‐Governor at the Opening of the First Session, Fortieth Parliament of the Province of British Columbia June 26, 2013. Victoria, BC. Available at: https://www.leg.bc.ca/40th1st/4‐8‐40‐1.htm Accessed: November 2014.

St. Christopher’s Hospice. Available at: http://www.stchristophers.org.uk/about/damecicelysaunders. Accessed January 17, 2015.

The Heart of Hastings. 2015. The Heart of Hastings Hospice. Available at: http://www.heartofhastingshospice.ca/index.php. Accessed January 22, 2015.

7.2 PERSONAL COMMUNICATIONS

Bazley, Anita. Clearwater Hospice Society. Telephone conversation December 16, 2014.

Brough, Heather. Program Coordinator, Hospice North Hastings. Telephone conversation on March 17 and April 22, 2015.

Chouinor, Kathleen. Program Director, Home Health Interior Health. Telephone conversations on January 28 and March 6, 2015.

Easson, Berni. Health Services Administrator, Thompson Cariboo Rural, Interior Health. Telephone conversations and e‐mails on February 27, April 23, and July 7, 2015.

Fortin, Alan. Councillor District of Barriere. Telephone conversation December 16, 2014.

Groulx, Leslie. Chief Administrative Officer, District of Clearwater. Telephone conversation on January 9, 2015.

Kershaw, Bill. Thompson Nicola Regional District Electoral Area O (Barriere) Representative. Telephone conversation on January 6, 2015.



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Kibble, Donna. Barriere Hospice Society. Telephone conversation December 16, 2014.

Lenny, Andrea. Clearwater Hospice Society. Telephone conversation December 15, 2014.

Milburn, Jane. Barriere Hospice Society. Telephone conversation December 17, 2014.

Minnie, Lana. 2015. Volunteer, Hospice North Hastings. Telephone conversation on March 5, 2015.

Osman, Jonathan. Interior Health. Email communication on April 24, 2015.

Paula, Pat. North Thompson Valley Hospice House Society. Telephone conversation December 16, 2014.

Quinn, Eilleen. 2015. Hospice Director, Heart of Hastings. Telephone conversation on March 2, 2015.

Sedgewick, Eileen. President of Clearwater Hospice Society. Telephone conversation December 16, 2014.

Schaffer, Carol. Thompson Nicola Regional District Electoral Area A (Vavenby) Representative. Telephone conversation on January 7, 2015.

Soles, John. 2015. Clearwater Doctor. Telephone conversation on January 23, 2015.

Weik, Rick. North Thompson Hospice House Society and Barriere Hospice Society. Telephone conversation December 15, 2014.