The Bromhead Boston Care Home Support Service Gill Garden Pilgrim Hospital Gillian.Garden@ulh.nhs.uk

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

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

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

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

Staff confidence in recognition, prevention & management of delirium

Effect of education on understanding of delirium

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)

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

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)

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

Advance Care Planning Progress

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

“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”

Place of Death

Admissions from Pilot Care Homes

Admissions from Pilot Care Homes

Admissions from Pilot Care Homes

Control Comparison

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

Thank You Any Questions?