1. Best Practice in End of Life Care:
Gold Standards Framework in Community Hospitals Programme
Jo Smith - End of Life Programme Facilitator
Ally Hardman – Locality Director & End of Life Care Lead

2. Aims of Gold Standards Framework in Community Hospitals
Quality of care – to improve the quality of care provided for all patients approaching the end of life and improving their experience of care
Coordination – to improve the coordination and collaboration of care within and between teams and across boundaries to ensure seamless care through improved organizational change.
Outcomes – to improve patient outcomes, reduce acute hospitalization in the final stages of life and enable more to live well and die well in their preferred place of care.

3. Accreditation Process
There are 4 parts to the GSF Accreditation Process:
Outcome measures –summary of key outcome ratios – evidence of attainment of standards in key areas
Audit
Patient – After death analysis (5 deaths + 5 discharges)
Staff – confidence & competency
Organisational – attainment of key changes
Portfolio of evidence – demonstrating attainment of the 5 standards plus patient case study & evidence of patient / carer feedback
Assessment – 3 hour ward assessment visit from the national GSF assessment team

4. The Five GSF Gold Standards
Right people – identification of patients nearing the end of life
Right care – assessing their needs: clinical & personal
Right place – planning coordinated cross boundary care
Right time – planning care in the final days
Every time – embedding consistent good practice and identifying areas to improve further

5. Right people – identifying the right patients
Are we identifying the right patients & recognizing them early enough?
Identify – on admission, identify whether the patient may be in the final year of life
Code – use needs based coding and plan pro-active care with core care plan (needs support matrices) to give right care at right time
Discuss – at regular multi-disciplinary team meetings the patients progress and pro-active care for the appropriate GSF code. Review regularly, recode as needed and review weekly as a minimum

7. GSF - Core Care Plans
To give pro-active care, ensuring that appropriate care is being co-ordinated to meet the needs of the patient
To give the patient the opportunity to discuss their wishes and preferences
To ensure effective communication & collaboration across care settings takes place aligned with the patient’s needs

8. Right Care – assessing their needs clinical & personal
Do we really know the patients and carer’s needs, wishes and preferences for care towards the end of their life?
Assess clinical needs – clinical assessment using holistic approach and referral as needed to appropriate specialist services
Assess personal needs – Advance Care Planning discussions: offer ACP discussion: (as capacity allows, best interests always considered)
Initial introductory conversation and information leaflet
Discussion of resuscitation status, preferred place of care and proxy spokesperson, LPA
Full ACP discussion initiated and recorded
Assess carer’s needs: informal carers and family are offered an assessment and are signposted and given appropriate support

9. Advance Care Planning
Umbrella term for the voluntary process of planning ahead for possible healthcare decisions
Enables communication of wishes, views and preferences
Usually in the context of an anticipated deterioration in the individual’s condition and/or changes to capacity

10. The Treatment Escalation Plan (TEP) and Resuscitation Decision Record
Documentation of plan of care for patients and whether they are for or not for cardiopulmonary resuscitation
Focus around the process / discussions with patients / families / carers
Adoption of one form across all of Cornwall's health community ensures continuity of care approach

11. Right Place – planning coordinated cross boundary care
Living Well: are we planning across boundaries?
Plan community support and care to reduce avoidable crises and readmissions
Communicate with receiving healthcare team / GP the needs based code and recommended actions and progress of advance care planning
Discharge planning – rapid discharge / fast track with appropriate follow up and referral in the community.

12. Right Time – planning care in the final days
Dying Well: are we enabling care aligned to patient preferences in the final days?
Care in the final days using five priorities of care guidance – individual end of life care plan
Anticipatory prescribing – Cornwall anticipatory prescribing guidance
Nominated clinician
Care after death - including providing support and understanding to the deceased’s family and significant others throughout all stages.

13. Individual End of Life Care Plans
Sensitive communication with the dying patient and those identified as important to them
Support of family members and those identified as important to the dying patient
Symptom control
Food and drink
Spiritual and religious care

14. Every time – embedding consistent good practice
How will we sustain and build on these improvements to ensure we provide consistent high quality care for everyone of our patients nearing the end of life?
compassionate care with dignity and respect for all patients / families
regular audit and review
weekly GSF key ratio outcomes
staff training & education
annual appraisal submission to the GSF national team

15. How do our patients benefit?
Physical symptoms are anticipated and reduced where possible, before they cause problems
They feel they have some choice and control and that choices around preferred place of care are discussed and recorded
They feel supported and informed and that potential problems are anticipated and reduced. This includes from admission right up to discharge.
Their family or carers feel enabled, informed and involved in their care and are supported as much as possible.

16. Any Questions?