Improving End of Life Care in Care Homes using GSF

1. Improving End of Life Care in Care Homes using GSF Lucy Giles Clinical Nurse AdvisorThe 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

2. Context- Why is End of Life Care important? Gomes and Higginson 2008 Projected -8%% +17% Source: Government Actuary Department 2004-based Projections for the UK

3. 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 • Approx80% care homes residents in final year of life • Approx30% 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

4. Elderly 'dying undignified death' “Many elderly fear being left on a geriatric ward to die. Many elderly people are left without proper palliative care and end up dying undignified deaths, a survey suggests.” BBC News 11 April 2006

5. 50% of frail care homes residents could have died at homeNAO report Nov 08

6. 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

7. ‘Win-win’- saving money and helping people die where they choose Context in care homes study in 1 PCT over 1 month Source: 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)

8. 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 Expenditures Life span

9. NOTE Most people die in hospital though evidence confirms that most would prefer to die at home Patient Choice- preferred and actual place of death

10. 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

11. 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,

12. Reduce hospitalisation Admissions avoidance policy Reduced length of stay- communication with hospitals – rapid discharge - better turnaround Appropriate admissions criteria Reflective practice as a team Proactive care- coding, communication, ACP, drugs, team planning, training etc

13. 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

14. Better Together GPs/DNs and care homes • Communication • Contact -. • Coding -Needs Support matrices • Proactiveplanning • Crisis admission Prevention • Reducing hospitalisation • Continuity 24 hours • Anticipatory prescribing • Collaboration • Agreement on protocols • Reflection- • Informal discussions-

15. 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.

16. 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

17. 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

18. The GSF Package has many tools Prognostic Indicator Guidance Advance Care Planning – Thinking Ahead New GSF IT Solutions and e-PIG Help populate EPaCCS / Locality Registers After Death Analysis - ADA Needs Based Coding New Virtual Learning Zone Needs Support Matrix GSF Care Plans Passport Information

19. 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

20. Decreased hospital admissions and deaths with GSFCH Training programme as measured by ADA phases 4-6

21. flagged up as prioritised care better access to GPs and nurses always get a visit on request proactive planning of respite passed on to doctor to phone back within 20 mins advance care plan – preferred place of care documented Out of Hours Primary Care easier prescriptions visit more likely if needed prioritised support for patient and carers GSF Patients coding collaboration GSF patient flagged on system Care Home Hospital collaboration with GP and GSF register ACP & DNAR noted and recognised ? open visiting referral letter recommends discharge back home quickly noted on readmission to hospital and STOP THINK policy and ACP care homes staff speak to hospital staff daily updating car park free? Benefits to Patients of Cross Boundary GSF

22. And the impact

23. 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’

24. 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

25. GSF enables a gold standard of care for all people nearing the end of life 1.Spread GSF Quality Improvement provides full package of support for all settings 3. Joined-up 2. Depth Integrated Cross boundary care GSF can be a common language • Quality assurance • Foundation Level • then Enhanced Level • to QR Accreditation e.g. Primary Care and care homes