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GSF Acute HospitalsTraining Programme
The right care, for the right people, in the right place, at
the right time, everytime
Overview Summary
1. Why is EOLC important? Quiz
• How many of your patients are likely to die this year? • What will most die from? • Where will most die? • How many hospital admissions are they likely to have
in their final year of life? • How many deaths in hospital could be at home? • What is the average cost of one admission?• Average length of stay in final hospital admission? • How often are they likely to see their GP in final year?• What proportion of your patients in the final year of
life are included on the palliative care/ GSF Register?
End of Life Care in Numbers• 1% of the population dies each year in UK – increasing • 75% deaths are from non-cancer/ long term/frailty conditions• 85% of deaths occur in people over 65 – elderly • 56% die in hospital- 35% home (18% home,17%care home)• 40-50% of those who died in hospital could have died at home• Over 60% people do not die where they choose
• £3,200- cost of every hospital admission- average 3 / final year • £19,000 non cancer, £14,000 cancer - av.cost/pt/final year
GMC Definition of ‘End of Life’GMC definwww.gmc-uk.org/static/documents/content/End_of_life.pdf
People are ‘approaching the end of life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with:
– advanced, progressive, incurable conditions– general frailty and co-existing conditions that mean they are expected to die
within 12 months– existing conditions if they are at risk of dying from a sudden acute crisis in
their condition– life-threatening acute conditions caused by sudden catastrophic events.
DeathEnd of Life Care
Supportive Care
Palliative Care
Terminal Care
Key MessagesEnd of Life Care is important and affects us all
Most die of non-cancer/co-morbidity in old age
Too few people die at home/in their place of choice
Hospital deaths are expensive and often avoidable
Everyone has a part to play
GSF helps improve quality of generalist care, coordination and reduce hospitalisation
GSF is used in the community and can help improve cross boundary integrated care
What if ….Bill Current Ideal
• In care home – condition worsening • Poor quality of life and crisis
admissions to hospital • Ad hoc visits -no future plan
discussed • Staff and family struggling to cope • No advance care planning, no life
closure discussion• Crisis- worsens at weekend - calls
999 paramedics admit to hospital- A&E- 8 hour wait on
trolley-dies on ward alone• Family given little support in grief -
staff feel let family down • No reflection by teams- no
improvement • Expensive for NHS - inappropriate
use of hospital
Using GSF• Identify and code stage• Assessment of clinical and personal needs• Advanced care planning • Planning - regular support + coordination
within primary care • Handover form out of hours • Crisis - discussion with family + GP • Admission averted • High quality care provided • Dies in care home • Bereavement care for family • Audit (ADA), reflection• Continuous Quality Improvement
• Better outcome for patient, family, staff • Most cost effective + best use of NHS
What difference does GSF make?
1. Quality - Attitude awareness and approach – Better quality patient experience of care – Greater confidence, awareness, focus and job
satisfaction
2. Coordination/Collaboration- structure, processes, and patterns
– Better organisation, coordination, documentation & consistency of standards
– Better communication between teams, co-working and cross-boundary care
3. Patient Outcomes – decrease hospitalisation, ACP alignment with patient preferences
– Reduced crises, hospital admissions, length of stay e.g. halve hospital deaths - more patients dying in preferred place
– Care delivered in alignment with patient and family preferences
OverviewOverview
Three key messages
1. Improve quality of care
2. Improve coordination, collaboration + cross- boundary care
3. Improve home care and decrease avoidable hospitalisation
GSF Primary Care and Domiciliary Care
CARE HOME GSF Care Homes
HOSPITAL GSF Acute Hospitals
Integrated Cross Boundary Care HOME
GSF Key Steps
patients who may be in the last year of life and identify their stage (‘Surprise’ Question + Prognostic Indicator Guidance + Needs Based Coding)
current and future, clinical and personal needs – advance care planning(using assessment tools, passport information, patient & family conversations, Advance Care Planning conversations)
care aligned to preferences, cross boundary care and care in the final days
identifyidentify
assessassess
planplan
What does it mean to be a GOLD patient ?
• Good communication between the patient and professionals involved in the planning their care
• On- going assessment of their clinical and personal
needs
• Living well until they die
• Dying with dignity in the place of their choice
What does being a GOLD patient mean to you?
1. Identify – the right patient GSF Prognostic Indicator Guidance
identifying patients with advanced disease in needof palliative / supportive care for register
Three triggers:
1. The surprise question ‘Would you be surprised if this person was to die within the next year?’
2. General Indicators for decline + comfort care/need
3. Clinical indicators
Suggested that all patients on register are offered an ACP discussion
identifyidentify
1. Identify- Needs Based Coding
Surprise question
Used of Needs based coding
Use of Needs Support Matrices • A - All - stable from diagnosis years• B - Unstable, advanced disease months• C - Deteriorating, exacerbations weeks• D - Last days of life pathway days
identifyidentify
Identify stage of illness deliver the right care at the right time for the right patient
Electronic Flagging
Bedweb
HCAS
EPaCCS
PAS
Locality Register
identifyidentify
System One
Lorenzo Alert
Health CommunityMorecambe Bay
Lorenzo Clinical Content Joy Wharton, Palliative Care Nurse Specialist
Health CommunityMorecambe Bay
Adding an End of Life Alert
Record Alert
Health CommunityMorecambe Bay
User clicks on drop down arrow to select
alert name
Alert name
Health CommunityMorecambe Bay
Clinician completes the onset date, alert
description and clicks the green add button to add it to the grid below.
Operation noteusing clinical note, problems & procedures
Health CommunityMorecambe Bay
Alert is visible via health issues, inpatient/outpatient pegboards. Information can be used to cite into documents or letters
Health CommunityMorecambe Bay
Why?
Commisioners
Surgeon e-log book
EPR Summary View
Emergency AdmissionSecure file
transfer to GPs
timely information to the GP
Accurate and timely coding
Easily accessible information
to support audit a
nd
improving care agenda
Helping to clinically
enrich the patient
record at a summery
level.
Offers clinicians relevant
reporting otherwise collected
manually
Keeps the ship financially
afloat
Improves relations with
commissioners
Quicker treatment at th
e
point of care.
Structured data can
alert clinicians of an
admission anywhere in
the Trust - IPNOne piece of information – many uses?
2. Assess - the right care
Assess their current and future,
clinical and personal needs
NEEDS Present Future
Clinical
Personal
AssessAssess
Assessment Tools
Specific Holistic
Pain chart or visual assessment score
PACA – problem and concerns assessment
Body chart PEPSICOLA
Doloplus or Abbey Pain scale - for suspected pain with dementia patients
Distress Thermometer
PAINAD - Pain assessment in advanced dementia
Goals of care
DS-DT – Discomfort scale
Many formal assessment tools are available nationally, and locally developed tools within your organisations can be used for all aspects of an holistic approach. Take time to review what is available and to see which type of assessment best suits your organisational need.
Assessment Tools fall into two groups: Specific & Holistic. Below are just a few examples of the commonly used tools.
Assessing pain in dementia care
• Never assume that dementia is the cause of all behaviour that you find challenging - it is a communication/an unmet need - often due to pain/distress
• Pain is commonly undetected and poorly managed - think physical/pain first• Assess - Doloplus/Abbey/DISDAT/Pain-AD
b. Assess personal needs
Advance Care Planning DiscussionHow?
Opportunistic informal conversationsFormalised systematic
What?What matters to you?What do you wish to happen? What do you do not want to happen?
Who?Named spokesperson (informal)Can tell those who act in best interests what sort of person you are
Lasting Power of Attorney (formal)Can make legal decisions regarding your health
Where?Preferred Place of Care Carer’s Preferred Place of Care
Other?Special instructions-Organ/tissue donation
ACP Dec 06 v 13
Gold Standards Framework and the Supportive Care Pathway Draft 7
Thinking Ahead - Advance Care Planning
Gold Standards Framework Advance Statement of Wishes The aim of Advance Care Planning is to develop better communication and recording of patient wishes. This should support planning and provision of care based on the needs and preferences of patients and their carers. This Advance Statement of wishes should be used as a guide, to record what the patient DOES WISH to happen, to inform planning of care. This is different to a legally binding refusal of specific treatments, or what a patient DOES NOT wish to happen, as in an Advanced Decision or Living Will. Ideally the process of Advance Care Planning should inform future care from an early stage. Due to the sensitivity of some of the questions, some patients may not wish to answer them all, or to review and reconsider their decisions later. This is a ‘dynamic’ planning document to be reviewed as needed and can be in addition to an Advanced Decision document that a patient may have agreed. Patient Name: Address: DOB: Hosp / NHS no:
Trust Details: Date completed:
Name of family members involved in Advanced Care Planning discussions: Contact tel: Name of healthcare professional involved in Advanced Care Planning discussions: Role: Contact tel: Thinking ahead…. What elements of care are important to you and what would you like to happen? What would you NOT want to happen?
assessassess
Advance care plan
ACPACP
Advance Care Planning
Deciding Right brings together advance care planning, the Mental Capacity Act, cardiopulmonary resuscitation decisions and emergency healthcare plans. At its core is the principle of shared decision making to ensure that care decisions are centred on the individual and minimise the likelihood of unnecessary or unwanted treatment
3. Plan- the right time and place Plan - Cross Boundary Care
Think…. Who needs to know about this patient?
How will you communicate this?
Where will information be documented and stored?
PlanPlan
Plan – Care in final days
Plan anticipatory ‘just in case’ thinking e.g. drugs, equipment
Plan care in final days e.g. using agreed care pathway e.g. LCP
Plan support for carers and in bereavement
PlanPlan
Benefits to Patients of Cross Boundary GSF
assessment & preferences noted
Community + others
Ambulance + out of hours
care – flagged and prioritised
Domiciliary care using
same coding and planning
Community hospitals
Acute Hospital
GSF patient identified and flagged on
system, registered
Better planning & collaboration with GP using GSF register
If readmitted to hospital - STOP THINK
policy and ACP
car park free and open
visiting
Care Home
care homes staff speak to hospital
regularly
ACP & DNAR noted and recognised
referral letter recommends discharge
back home quickly
Primary Care
advance care plan – preferred place of care documented
proactive planning of care
Better assessment + ACP discussions
offered
Earlier identification of patients in final year of
life
better provision +
access to GPs and nurses
prioritised support for patient and
carers + easier prescribing
coding Collaboration
with care home
Gold Patients
Putting Patients at the Centre of Care
Hospices
planplan
AwarenessAwareness
Session 6
Session 5
Session 4
Session 3
Session 1
Session 2
• Plan anticipatory EOL care for patient and support for carers
• Overview - bringing it back together - lessons learnt
• Overview of End of Life Care and GSFAH Programme• Why do we need to improve?
• Identifying the patients nearing the end of life by using needs based coding
• Assess patients’ and carers clinical and personal needs
• Plan good cross boundary care to help reduce hospital admissions and length of stay
Plan
Assess
Awareness
Identify
Embed
Care in final days
The GSF Acute Hospitals Training Programme:
Session Overview
The Five GSF GoldGSF Acute Hospital Accreditation
• Standard 1 - Right people • identifying the right patients
• Standard 2 - Right care • assessing their needs clinical and personal
• Standard 3 - Right place • planning coordinated cross boundary care
• Standard 4 - Right time • Proactively planning care including in final days
• Standard 5 - Every-time • Embedding consistency of good practice, extending
further and integrating cross boundary care