1. The Bromhead Boston Care Home Support Service
Gill Garden
Pilgrim Hospital

2. Background
> 200 admissions from care homes to ULH during 3 week period in November 2009
January 2010: Chance meeting member of local charity workshop
Discussion with Trust HQ & with PCG
March 2010: Business case presented to charity
Funding for two year care home pilot secured

3. Care Home Liaison Service Proposed
8 care homes (274 places) in Boston
Staffing
2 WTE staff (bands 7&6)
Support from Liaison Psychiatrist (in post)
Phased introduction:
Identification of residents with dementia
Training of care home staff
Care planning
Outreach service:
To assess & advise whether treatment can be instituted at home or admission required
To advise re institution of palliative care

5. Foundations Agreement secured: CCG, GPs & care homes
Background information drawn up
GPs, care home, carers’ letters
Information leaflets: delirium, feeding, end of life care
Educational programme devised
Register of residents with dementia
Care home data
GP dementia registers

6. Education in Care Homes
Stop Delirium! *
Delirium information given to care homes
Education sessions delivered in care homes
Effectiveness measured by pre/post education surveys
Dysphagia & comfort feeding
Teaching package developed with speech & language therapists
Comfort feeding leaflet given to care homes
*University of Leeds 2007

7. Staff confidence in recognition, prevention & management of delirium

8. Effect of education on understanding of delirium

9. Gold Standard Framework (GSF) Prognostic Indicator Guidance
Unable to walk without assistance and
Urinary & faecal incontinence and
No consistently meaningful conversation and
Unable to do activities of daily living and
Barthel score <3
Plus any one of following
Weight loss & reduced oral intake
10% weight loss in 6/12 without other cause
Albumin <25 g/l
Aspiration pneumonia
Recurrent fever, pyelonephritis or UTI
Severe pressure sores (grade III/IV)

10. Individual Resident Assessment
Presence of dementia/suspected dementia
Nutrition: MUST
ADLs: Barthel
Waterlow
Cognitive assessment

11. Advance Care Planning Most frail & dependent prioritised
Mental Capacity Assessment
Advance Care planning:
families approached by care home staff
undertaken on best interests basis
meetings involve:
Staff, family/close friends or those with POA
History, current health, prognosis & end of life care discussed
Liaison Psychiatrist only for residents without next of kin (IMCA requested but declined)

12. Advance Care Plans (ACP)
Implementation of
Advance Care Plans (ACP)
ACP sent to care home, GP, ambulance & out of hours services
DNACPR forms completed by care home liaison nurses & endorsed by GP
Care homes receive frequent support & guidance in the practicalities of using the ACP
30 residents have died in their preferred place of care because an ACP was in place

13. Advance Care Planning Progress

14. Carer Satisfaction
After completion of ACP carers asked to complete anonymous satisfaction questionnaire
Results evaluated using Survey Monkey providing quantitative and qualitative data
Very positive feedback: 92.6% of respondents rated the service 9/10 or 10/10

15. “Found the nurse to be very helpful in her explanations of all questions I asked. All was put in a very easy to understand way. I think this idea of advanced planning is very good, & allows relatives input into their family members care instead of being made to feel it is nothing to do with you”
Carer Satisfaction
“Excellent service”
“My mum had made a living will & it was something she always talked about with her family, this process has given me the confidence to know my mum’s “voice” will be heard even though she can no longer communicate effectively. As a family we also feel we have been given the opportunity to be “heard” for the first time”
“I met with the nurse & although I understood what an advanced care plan was I found it comforting to discuss the details with a nurse who showed so much empathy & understanding. If I have any queries in the future I wouldn’t hesitate to contact the nurse knowing that she would find time to talk to me without judging”

16. Place of Death

17. Admissions from Pilot Care Homes

18. Admissions from Pilot Care Homes

19. Admissions from Pilot Care Homes

20. Control Comparison

21. To secure permanent funding
Future Plans
Advance care planning for all inpatients (existing or future care home residents)
Involvement of hospital staff in care planning
Expansion of inclusion criteria to include frailty
Expand geographic area & thus number of people offered this service
To secure permanent funding

22. Thank You
Any Questions?