2 “Its about living well until you die” Our aspiration is to deliver training and support that brings about individual and organisational transformation, enabling a ‘gold standard’ of care for all people nearing the end of life .
3 End of Life care is everybody’s business Do any of the people you care for ever die? Then you need to think about end of life care.
4 Clarification of Terms End of Life care‘Care that helps all those with advanced progressive incurable illness to live as well as possible until they die’Supportive CareHelping the patient and family cope better with their illnessPalliative carespecialist / palliative care -holistic care (physical psychological, social, spiritual )Final days/Terminal careDiagnosing dying-care in last hours and days of lifeEnd of Life CareSupportive CarePalliative CareFinal days/ Terminal CareDeath
5 End of Life Care in Numbers 1% of the population dies each year17% increase in deaths from 201260-70% people do not die where they choose35% home death rate – 18% home, 17% care home40% of deaths in hospital could have occurred elsewhere75% non-cancer ,85% of deaths occur in people over 65£19k non cancer ,£14k cancer - av.cost/pt/final year.
6 3) Lay People- general public 1) Specialists2) Generalists - GSF3) Lay People- general publicHospice and Specialist Palliative CareWorkforce 5,500Enabling GeneralistsPrimary CareCare HomesHospitalDomiciliary careWorkforce -2.5 mPublic AwarenessCommunity CareCarers Support etcPopulation 60m
8 What is The Gold Standards Framework? Enabling generalists inend of life careFrameworks to deliver a‘gold standard’ of carefor all people nearingthe end of life“Every organisation involved in providing end of life care will be expected to adopt a coordination process , such as the GSF”DH End of Life Care Strategy July 08
9 Aim of GSFAim is to develop an organisational -based system to improve the organisation and quality of care of service users in the last year/s of life in the community.
10 What does GSF aim to do? 3 Key messages Improve quality of care Decrease hospitalisation and cost Improve cross boundaryteamwork + collaboration
11 GSF is about … Enabling Generalists - improving confidence of staff Person- led -focus on meeting person and carer needsCare for all people -non-cancer, frailPre-planning care in the final year of life -proactive careOrganisational system changeCross boundary care- home ,care home, hospital, hospice, Care closer to home – decrease hospitalisation
12 Improve organisation of care Head Hands and Heart - systems -GSF- ‘how to do it’HEAD- knowledge- clinical competence- ‘what to do’HEART-compassionate careexperience of care ’why’- human dimension-
13 GSF Training Programmes GSF Primary CareFrom foundation GSF mainstreamed (QOF)90% GP practices have palliative care register and meetingJune 09 Next Stage GSF launched updated GSFNew training programme + quality recognitionGSF Care HomesFrom Over 1500 care homes trainedDeveloped training and accreditation programmes100 / year accreditedGSF Acute HospitalsFrom Phase 1 pilot 15 hospitalsPhase 2 Spring 2011Improving cross boundary careGSF Domiciliary CareFrom 2011 –phase 1 –Manchester, Birmingham, Rotherham8-10 domiciliary care agencies, carers per agency
18 GSF Toolkit Advance Care Planning – Thinking Ahead Prognostic Indicator Guidance – PIG + Surprise QuestionsPassport InformationUse of templates in Locality RegistersPt needsSupport from hospital/SPCSupport from GPYearsMonthsWeeksDaysNeeds Support MatrixAfter Death Analysis - ADA
20 Support Support from your local trainer/ facilitator 2 whole day WorkshopsGSF ResourcesGPGWorkbook folderDVD
21 2. Needs Based CodingIdentify stage of illness- to deliver the right care at the right time for the right patientA - All – stable from diagnosis yearsB – Unstable, advanced disease monthsC – Deteriorating, exacerbations weeksD - Last days of life pathway days
22 Identify- GSF Prognostic Indicator Guidance- identifying pts with advanced disease in need of palliative/ supportive care/for registerThree triggers:Surprise question-‘Would you be surprised if this person was to die within the next year?’Patient preference for comfort care/needClinical indicatorsSuggested that all pts on register are offered an ACP discussion
23 Goals of Care Person-centred’ care Considering Goals of Care, along with the advance care planning discussion, can help determine the most appropriate way forward , tailored to the needs of each personIncludes considering admission to hospital, or inappropriate interventions eg PEG feeding, DNAR status, when the preference is for comfort care and quality of life.Includes quality of life issues and quality of death
24 The Gold Standard of end of life care “The care of ALL dying patientsis raised to the level of the best.”(NHS Cancer Plan 2000)Applications of learningfrom cancer pts to theother 3 out of 4 patients
25 Goals of GSF Patients are enabled to have a ‘good death’ 1) symptoms controlled2) in their preferred place of choice3) Safe +secure with fewer crises.4) Carers feel supported, involved, empowered, and satisfied.5)Staff confidence, teamwork,satisfaction, co-workingwith specialists and communication better.
26 Skills for Care and Skills For Health Common Core Competences: Care planningSymptom controlAdvance care planningCommunication Skills
27 What are the issues you face in providing good end of life care?
28 The Challenges in Domiciliary Care Isolation/Lone workersCommunication with others e.g. GPs, DNsNot being valued by other professionalsNo Pathways or plans for end of life careLack of collaboration & identification of people at the end of lifeInappropriate admissions at the end of lifeConfidence of staff
30 How GSF addresses these challenges Session 1 Context of end of life care and the role of the carer within the extended teamSession 2 Identify people nearing the end of lifeSession 3 Assess – Clinical understanding of what to do
31 Session 4 Assess – Personal preferences Session 5 Plan- care in the final days of lifeSession 6 Plan – Cross Boundary Care
32 Reactive patient journey- MR B in last months of life- GP and DN ad hoc arrangements-no PPOD discussed or anticipated/no anticipatory careProblems with symptom control-high anxietyCrisis call e.g. OOH-no plan or drugs availableAdmitted to hospital (?Bed blocks?)Dies in hospital -?over intervention/medicalisedCarer given minimal support in griefNo reflection/improvements by team/PCT? Inappropriate use of hospital bed?
33 GSF Proactive pt journey- Mrs W in last mths of life On SC Register-discussed at PHCT meetingDS1500 and info given to pt +carer(home pack)Home care team involved in planning & deliveryRegular support, visits phone calls-proactiveAssessment of symptoms-?referral to SPC-customised care to pt and carer needsCarer assessed including psychosocial needsPreferred place of care noted and organisedHandover form issued –drugs issued for homeEnd of Life pathway/LCP/protocol usedPt dies in preferred place-bereavement support Staff reflect-SEA, audit gaps improve care, learn
34 Better team-working and collaboration with GPs and others Talking a common language (incl coding)Earlier prediction of needsAdvance Care Planning helps focus on personal goals of careBetter agreed documentation eg DNARPreparation eg anticipatory prescribing, LCPBetter morale and mutual confidence
35 Benefits to Patients of Cross Boundary GSF GSF PatientsOut of Hoursflagged up as prioritised carepassed on to doctor to phone back within 20 minsvisit more likely if neededHospitalGSF patient flagged on systemcollaboration with GP and GSF registernoted on readmission to hospital and STOP THINK policy and ACPcar park free?? open visitingCareHomecare homes staff speak to hospital staff daily updatingACP & DNAR noted and recognisedreferral letter recommends discharge back home quicklyPrimary Careadvance care plan – preferred place of care documentedproactive planning of respitealways get a visit on requestbetter access to GPs and nurseseasier prescriptionsprioritised support for patient and carerscodingcollaboration
36 Reduce hospitalisation Admissions avoidance policyReduced length of stay better communication with hospitals – rapid discharge - better turnaroundAppropriate admissions criteriaReflective practice as a teamProactive care- coding, communication, ACP, drugs, team planning, training etc
37 GSFDC Training Programme Assessment BeforeAssessment AfterSession 1 Training Event6 Learning SessionsSession 6 Training & FeedbackPlanningGSF for Domiciliary Care Teams
38 Its about living well until you die www. goldstandardsframework. org Its about living well until you die