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