1. The Bromhead Care Home Service: Phases 1 & 2
Gill Garden
United Lincolnshire Hospitals NHS Trust

2. 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:
Caplan et al. (2006) Age and Ageing, 35:
3/3/2015

3. 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

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

5. 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

6. Phase 1: Outcomes
Training

7. 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

8. 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”

9. 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

10. 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 .

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

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

13. Cognitive Impairment

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

15. Preferred Place of Care & Place of Death

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

17. 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

18. 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

19. 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?

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