The Bromhead Care Home Service: Phases 1 & 2 Gill Garden United Lincolnshire Hospitals NHS Trust gill.garden@stbarnabashospice.co.uk

Evidence Care Homes: Many residents have dementia Life expectancy is poor People with advanced dementia: Have poor outcomes from hospital admission Are more likely to have interventions Are less likely to be offered palliative care Advance care planning has been shown to reduce hospital admissions without increasing mortality 62% have dementia 16% all deaths occur in care homes DOH 2008 Median length of stay 12 months in NH; 27 months in RH 4 times the mortality for patientsx with advanced dementia ( sampson ) 50%- 70% of residents die within 2 years of entering NH especially in first 6 months Royal College of Psychiatrists (2005) Who Cares Wins Molloy et al. (2000) JAMA, 283: 1437-1444 Caplan et al. (2006) Age and Ageing, 35: 581-585   3/3/2015

Phase 1: 2011 Funding: The Bromhead Medical Charity Staff: 2 RGNs + consultant support (unfunded) Location: 7 care homes in Boston, Lincolnshire Patients: residents with dementia Service Training on delirium, eating, drinking & dysphagia GSF assessment (most frail prioritised) Care planning

Individual Resident Assessment Presence of dementia/suspected dementia Nutrition: MUST Activities of Daily Living: Barthel Waterlow Cognitive assessment 3/3/2015

Implementation of Advance Care Plans Most frail & dependent prioritised Mental Capacity Assessment Care planning: families approached by care home staff undertaken on best interests basis meetings involve: Staff, family/close friends /POA History, current health, prognosis & end of life care discussed IMCA for residents without NOK Care Plans sent to care home, GP & filed in medical notes DNACPR forms completed by care home liaison nurses & endorsed by GP Frequent support in the practicalities of using the ACP Involvement of palliative care services when time appropriate 3/3/2015

Phase 1: Outcomes Training

Admissions from Care Homes Information about hospital admissions was obtained for the financial year prior to the star of the service and then monthly thereafter. The fall seen in the first year was exceeded in the second with a 55% reduction from baseline. To date for this financial year, we have collected data for 5 months, which if extrapolated for the full 12 month period suggests that the service is on target for a similar level of reduction from baseline. 3/3/2015

Carer Feedbacker SatisfactionCarer “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 Feedbacker SatisfactionCarer “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”

Phase 2: What we are doing now Funding: The Bromhead Medical Charity Staff: (3.25WTE): 1 medic, 1 OT, 1 physio, 2 nurses Patients: residents in 24 Lincoln care homes Service Model Care Homes randomised to avoid selection bias Step Wedge All residents to be offered CGA & ACP

Phase 2: Service Evaluation Health Service Utilisation Admissions Secondary Care Investigations/interventions* Primary care intervention* Deaths Overall number Deaths in preferred place of care Carer Satisfaction In our view care planning has been the major cornerstone for this service. In order to maximise the effectiveness of the service, those residents most likely to be admitted to hospital were prioritised. We were aware that physical decline in people with dementia is often insidious, and there is a lack of awareness of the features which mark the last phase of life. Therefore we undertook holistic assessments using the Gold Standards Framework prognostic indicators, thereby assessing nutritional status, mobility, tissue viability, functional status cognition and Mental Capacity. This information proved extremely helpful in informing subsequent conversations that were held with family and significant others to discuss prognosis and end of life care. Most of the residents with dementia lacked mental capacity the discuss their end of life care and so care planning proceeded on a best interests basis. We found that families often needed several meetings to help them reflect of their wishes before drawing up a careplan .

Comprehensive Geriatric Assessments Hartsholme reflects more mentally frail residents Over 50% of all residents seen meet severe frailty criteria on EFS

Degree of Frailty and GSF Status Hartsholme reflects more mentally frail residents Over 50% of all residents seen meet severe frailty criteria on EFS

Cognitive Impairment

Advance & Anticipatory Care Plans Hartsholme reflects more mentally frail residents Over 50% of all residents seen meet severe frailty criteria on EFS

Preferred Place of Care & Place of Death

Relationship of ACP/AnCP v ACP Declined v No ACP on Place of Death

New Interventions Key worker designated for each care home Red wallet DNACPR ACP/AnCP Hospital Information Pack EPaCCs on Systm1 EMAS: sticker on care home door alerting EMAS staff to red wallets/DNACPR/ACP being used

What have we learnt so far.. ACPs greatly increase chances of dying in PPofC Implementation more challenging in Residential Homes Individual care home culture crucial Response has been overwhelmingly positive Confounding external factors: Care homes: Deregistration of nursing beds Qualified Staff –switch to RMNs Staff with entrenched attitudes Support EMAS GP cover and perspectives IT Systems need to be accessible and compatible

Challenges Patients transferred from LCH to care homes, particularly fast track Universal use of red wallets and HIP packs IT system communication:GPs, hospital, LCHS What the service should be part of Neighbourhood teams/LCHS? ULHT? St Barnabas? Will service be commissioned in some format?

Any Questions? gill.garden@stbarnabashospice.co.uk The End Any Questions? gill.garden@stbarnabashospice.co.uk