Improving End of Life Care in Care Homes using GSF

Lucy GilesClinical Nurse Advisor

The National GSF Centre in End of Life Care

The leading EOLC training centre enabling generalist frontline staff to deliver a ‘gold standard’ of care for all people nearing the end of life

Context- Why is End of Life Care important?

Source: Government Actuary Department 2004-based Projections for the UK

+17%-8%%

Projected

Gomes and Higginson 2008

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 Approx 80% care homes residents in final year of life Approx 30% hospital patients are in final year of life

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

Elderly 'dying undignified death'

“Many elderly fear beingleft on a geriatric ward todie. Many elderly peopleare left without properpalliative care and endup dying undignified deaths, a survey suggests.” BBC News 11 April 2006

50% of frail care homes residents could have died at home NAO report Nov 08

Where Care Home Residents DiedGrossed up, estimated total deaths = 128

Hospital, no alternative

20%

Hospital, with alternative

19%Died in care home

61%

DH End of Life Care StrategyJuly 08

4.30 (p 91) “Inadequate training of staff at all levels within care homes, sheltered housing and extra care housing sector ..is considered to be the single most important factor”

• Factors leading to suboptimal care – Lack of ACP– Inadequate recognition and holistic assessment– Death concerns– Impact on other residents– Inadequate access to NHS services– Inadequate medicine reviews– Training

‘Win-win’- saving money and helping people die where they choose

Context in care homes study in 1 PCT over 1 monthSource: National Audit Office/RAND analysis (2008)

• A quarter of care homes residents deaths occurred in hospital• 40% of those had no medical reason to be in hospital

– 1500 bed days (£250/day) = £375,000 in 1 month = £4.5m/year • It is estimated that by reducing hospital bed days by 10% and av. length of stay

by 25% - £104 million could be redeployed to support dying in usual place of care in community

• Education alone in care homes doesn’t work- need change management skills to embed new system plus supported learning

(Froggatt et al)

Cost effectiveness

• £3,200- cost of every hospital admission- • average 3 / final year • What could you buy for 1 saved admission ?

• People + Services – D. Nursing / home care• Training eg GSF = 1-2 care homes full 1

year GSF training or 5 GP practices

Exp

endi

ture

s

Life span

Patient Choice- preferred and actual place of death

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Preference forplace of death

Where peoplewith cancer die

Where people die-all causes

Other

Nursinghome

Hospital

Hospice

Home

NOTE Most people die in

hospital though evidence confirms that most would prefer to die at

home

Care closer to home Reducing hospitalisation

• Advance care planning discussions

• Needs Based Coding • Needs Support Matrices• Planning meetings• Team collaboration• DNaR/ AND discussions • Training and education for all

staff (including night staff and temp/ bank)

• Policy +guidance on reducing avoidable admissions

• Stop Think policy • Anticipatory prescribing• OOH handover form• Audit/ SEA • LCP for dying • Communication with family re

ACP

Communication summary

• Contact -Effective means of communication –GP Practices including these residents on their palliative care/GSF registers, meetings, emailing coding.

• Coding - proactive care using the needs based coding of residents, reviewing together the Needs Support matrices

• Proactive planning and regular visits to the care homes, especially focussing on those in the C and D codes/ yellow and red, personal lists coded etc,

Reduce hospitalisation1. Admissions avoidance policy

2. Reduced length of stay- communication with hospitals – rapid discharge - better turnaround

3. Appropriate admissions criteria

4. Reflective practice as a team

5. Proactive care- coding, communication, ACP, drugs, team planning, training etc

Agreement on protocols and policies in the home

• use of care pathway for the dying (eg LCP) ,• DNAR forms,• decreasing hospitalisation policies,• when is it appropriate to call GPs, • out of hours providers, • Verification of death ,• advance care planning discussions , • discussions with relatives etc

Better Together GPs/DNs and care homes

• Communication – Contact -.– Coding - Needs Support matrices – Proactive planning

• Crisis admission Prevention

– Reducing hospitalisation – Continuity 24 hours – Anticipatory prescribing

• Collaboration

– Agreement on protocols – Reflection- – Informal discussions-

Undignified dying Over 50% of people still die in hospital, many in transit

or A&E , but most say they want to die at home.

At individual Level - BillProactive planning

• 82 year old in care home -COPD, frailty+ other conditions • 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

Unacceptably poor level of care

especially for the elderly

GSF Five Standards

• Right person – identifying the population, communicating this to others • Right care – assessing needs, preferences and care required + providing services • Right place – reducing hospitalisation enabling more to live and die at home • Right time – proactive planning, fewer crises, predicted care in final days of life • Every-time – consistency of practice

The GSF Package has many tools

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?

Pt needs

Support from hospital/SPC

Support from GP

Years

Months

Weeks

Days

Prognostic Indicator Guidance

After Death Analysis

- ADA

Advance Care Planning – Thinking Ahead

Needs Support Matrix

GSF Care Plans

Help populate EPaCCS / Locality Registers

Passport Information

New GSF IT Solutions and e-PIG

New Virtual Learning Zone

Needs Based Coding

Underlying themes to optimise care• Pre-planning of care

– Coding, ACP, planning meetings, GP collaboration, Anticipatory Rx, handover form, LCP protocol

• Communication – listening, talking + recording

• Team Working– within care home, with GPs and with others

• Clinical care– Assessment and management

• Decrease hospitalisation– Admission avoidance, decrease length of stay, rapid

discharge

Decreased hospital admissions and deaths with GSFCH Training programme

as measured by ADA phases 4-6

25.10%

15.75%

9.40%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Stage 1 (pretraining)

Stage 2 (posttraining)

Accreditation stage

Hospital deaths

53.15%

35.50%30%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Stage 1 (pretraining)

Stage 2 (posttraining)

Accreditation stage

Crisis admissions

GSF Patients

Out of Hours

flagged up as prioritised

care

passed on to doctor to

phone back within 20 mins

visit more likely if needed

Hospital

GSF patient flagged on system

collaboration with GP and GSF register

noted on readmission to hospital and STOP THINK policy and ACP

car park free?

? open visiting

Care Home

care homes staff speak to hospital

staff daily updating

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

respite

always get a visit on request

better access to GPs and

nurses

easier prescriptions

prioritised support for patient and

carers

coding collaboration

Benefits to Patients of Cross Boundary GSF

And the impact

0 1 2 3 4 5 6 7 8 9 10+0

100

200

300

400

500

600

3 59 14 21

3447

6485

100

151

2031

5174

115

151

200

242

318

342

479

Potentially preventable admissionOther emergency admissions

No of conditions

Annu

al a

dmis

sion

rate

per

100

0 pa

tient

s

Improving End of Life Care with GSF Head Hands and Heart

HEAD

Evidenced-based knowledge, clinical competence

‘what you know’

HANDS

Systems minded care coordination

‘what you do’

HEART

person-centred compassionate care

‘the way you do it’

Key Messages End 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

GSF enables a gold standard of care for all people nearing the end of life

1.Spread

2. Depth Quality assurance

Foundation Level then Enhanced Levelto QR Accreditation e.g. Primary Care and care homes

3. Joined-up

GSF Quality Improvement provides full package of support for all settings

Integrated Cross boundary care GSF can be a common language