1. Introduction to the Gold Standards Framework
Domiciliary Care Training Programme
Maggie Stobbart-Rowlands, Lead Nurse, GSF Central Team
GSF Domiciliary Care Good Practice Guide February 2011 Copyright © Used under licence by the Gold Standards Framework Centre CIC

2. “Its about living well until you die” Our aspiration is to deliver training and support that brings about individual and organisational transformation, enabling a ‘gold standard’ of care for all people nearing the end of life .

3. End of Life care is everybody’s business
Do any of the people you care for ever die? Then you need to think about end of life care.

4. Clarification of Terms
End of Life care
‘Care that helps all those with advanced progressive incurable illness to live as well as possible until they die’
Supportive Care
Helping the patient and family cope better with their illness
Palliative care
specialist / palliative care -holistic care (physical psychological, social, spiritual )
Final days/Terminal care
Diagnosing dying-care in last hours and days of life
End of Life Care
Supportive Care
Palliative Care
Final days/ Terminal Care
Death

5. End of Life Care in Numbers
1% of the population dies each year
17% increase in deaths from 2012
60-70% people do not die where they choose
35% home death rate – 18% home, 17% care home
40% of deaths in hospital could have occurred elsewhere
75% non-cancer ,85% of deaths occur in people over 65
£19k non cancer ,£14k cancer - av.cost/pt/final year .

6. 3) Lay People- general public
1) Specialists
2) Generalists - GSF
3) Lay People- general public
Hospice and Specialist Palliative Care
Workforce 5,500
Enabling Generalists
Primary Care
Care Homes
Hospital
Domiciliary care
Workforce -2.5 m
Public Awareness
Community Care
Carers Support etc
Population 60m

7. The key role of generalist frontline carers
‘Its less about what you know…
…its more about what you do and how you do it’
Identifying important triggers - being aware of patients nearing end of life
Assessing needs and wishes
Planning care - Knowing when and where to get help -Playing role in system – cross boundary care
Communicating well-Sharing information
GSF Domiciliary Care Good Practice Guide February 2011 Copyright © Used under licence by the Gold Standards Framework Centre CIC

8. What is The Gold Standards Framework?
Enabling generalists in
end of life care
Frameworks to deliver a
‘gold standard’ of care
for all people nearing
the end of life
“Every organisation involved in providing end of life care will be expected to adopt a coordination process , such as the GSF”
DH End of Life Care Strategy July 08

9. Aim of GSF
Aim is to develop an organisational -based system to improve the organisation and quality of care of service users in the last year/s of life in the community.

10. What does GSF aim to do? 3 Key messages
 Improve quality of care
 Decrease hospitalisation and cost
 Improve cross boundary
teamwork + collaboration

11. GSF is about … Enabling Generalists - improving confidence of staff
Person- led -focus on meeting person and carer needs
Care for all people -non-cancer, frail
Pre-planning care in the final year of life -proactive care
Organisational system change
Cross boundary care- home ,care home, hospital, hospice, Care closer to home – decrease hospitalisation

12. Improve organisation of care Head Hands and Heart
- systems -GSF
- ‘how to do it’
HEAD
- knowledge
- clinical competence
- ‘what to do’
HEART
-compassionate care
experience of care ’why’
- human dimension-

13. GSF Training Programmes
GSF Primary Care
From foundation GSF mainstreamed (QOF)
90% GP practices have palliative care register and meeting
June 09 Next Stage GSF launched updated GSF
New training programme + quality recognition
GSF Care Homes
From Over 1500 care homes trained
Developed training and accreditation programmes
100 / year accredited
GSF Acute Hospitals
From Phase 1 pilot 15 hospitals
Phase 2 Spring 2011
Improving cross boundary care
GSF Domiciliary Care
From 2011 –phase 1 –Manchester, Birmingham, Rotherham
8-10 domiciliary care agencies, carers per agency

15. Deliver coordinated care in line with preferences

16. Three key bottlenecks that GSF helps with
Identification of all patients
particularly those with non cancer
Difficult conversations with patients and families,
advance care planning discussions
Effective team pre-planning-
predicting needs- change to more proactive care
Overcome to avoid crises and deliver care more aligned to the wishes of patients and their families.
GSF Domiciliary Care Good Practice Guide February 2011 Copyright © Used under licence by the Gold Standards Framework Centre CIC 16

17. GSF 3 Steps identify assess plan
GSF Domiciliary Care Good Practice Guide February 2011 Copyright © Used under licence by the Gold Standards Framework Centre CIC

18. GSF Toolkit Advance Care Planning – Thinking Ahead
Prognostic Indicator Guidance – PIG + Surprise Questions
Passport Information
Use of templates in Locality Registers
Pt needs
Support from hospital/SPC
Support from GP
Years
Months
Weeks
Days
Needs Support Matrix
After Death Analysis - ADA

19. GSF 7 C’s

20. Support Support from your local trainer/ facilitator
2 whole day Workshops
GSF Resources
GPG
Workbook folder
DVD

21. 2. Needs Based Coding
Identify stage of illness- to deliver the right care at the right time for the right patient
A - All – stable from diagnosis years
B – Unstable, advanced disease months
C – Deteriorating, exacerbations weeks
D - Last days of life pathway days

22. Identify- GSF Prognostic Indicator Guidance- identifying pts with advanced disease in need of palliative/ supportive care/for register
Three triggers:
Surprise question-
‘Would you be surprised if this person was to die within the next year?’
Patient preference for comfort care/need
Clinical indicators
Suggested that all pts on register are offered an ACP discussion

23. Goals of Care Person-centred’ care
Considering Goals of Care, along with the advance care planning discussion, can help determine the most appropriate way forward , tailored to the needs of each person
Includes considering admission to hospital, or inappropriate interventions eg PEG feeding, DNAR status, when the preference is for comfort care and quality of life.
Includes quality of life issues and quality of death

24. The Gold Standard of end of life care
“The care of ALL dying patients
is raised to the level of the best.”
(NHS Cancer Plan 2000)
Applications of learning
from cancer pts to the
other 3 out of 4 patients

25. Goals of GSF Patients are enabled to have a ‘good death’
1) symptoms controlled
2) in their preferred place of choice
3) Safe +secure with fewer crises.
4) Carers feel supported, involved, empowered, and satisfied.
5)Staff confidence, teamwork,
satisfaction, co-working
with specialists and communication better.

26. Skills for Care and Skills For Health Common Core Competences:
Care planning
Symptom control
Advance care planning
Communication Skills

27. What are the issues you face in providing good end of life care?

28. The Challenges in Domiciliary Care
Isolation/Lone workers
Communication with others e.g. GPs, DNs
Not being valued by other professionals
No Pathways or plans for end of life care
Lack of collaboration & identification of people at the end of life
Inappropriate admissions at the end of life
Confidence of staff

30. How GSF addresses these challenges
Session 1 Context of end of life care and the role of the carer within the extended team
Session 2 Identify people nearing the end of life
Session 3 Assess – Clinical understanding of what to do

31. Session 4 Assess – Personal preferences
Session 5 Plan- care in the final days of life
Session 6 Plan – Cross Boundary Care

32. Reactive patient journey- MR B in last months of life-
GP and DN ad hoc arrangements-no PPOD discussed or anticipated/no anticipatory care
Problems with symptom control-high anxiety
Crisis call e.g. OOH-no plan or drugs available
Admitted to hospital (?Bed blocks?)
Dies in hospital -?over intervention/medicalised
Carer given minimal support in grief
No reflection/improvements by team/PCT
? Inappropriate use of hospital bed?

33. GSF Proactive pt journey- Mrs W in last mths of life
On SC Register-discussed at PHCT meeting
DS1500 and info given to pt +carer(home pack)
Home care team involved in planning & delivery
Regular support, visits phone calls-proactive
Assessment of symptoms-?referral to SPC-customised care to pt and carer needs
Carer assessed including psychosocial needs
Preferred place of care noted and organised
Handover form issued –drugs issued for home
End of Life pathway/LCP/protocol used
Pt dies in preferred place-bereavement support Staff reflect-SEA, audit gaps improve care, learn

34. Better team-working and collaboration with GPs and others
Talking a common language (incl coding)
Earlier prediction of needs
Advance Care Planning helps focus on personal goals of care
Better agreed documentation eg DNAR
Preparation eg anticipatory prescribing, LCP
Better morale and mutual confidence

35. Benefits to Patients of Cross Boundary GSF
GSF Patients
Out of Hours
flagged up as prioritised care
passed on to doctor to phone back within 20 mins
visit more likely if needed
Hospital
GSF patient flagged on system
collaboration with GP and GSF register
noted on readmission to hospital and STOP THINK policy and ACP
car park free?
? open visiting
Care
Home
care homes staff speak to hospital staff daily updating
ACP & DNAR noted and recognised
referral letter recommends discharge back home quickly
Primary Care
advance care plan – preferred place of care documented
proactive planning of respite
always get a visit on request
better access to GPs and nurses
easier prescriptions
prioritised support for patient and carers
coding
collaboration

36. Reduce hospitalisation
Admissions avoidance policy
Reduced length of stay better communication with hospitals – rapid discharge - better turnaround
Appropriate admissions criteria
Reflective practice as a team
Proactive care- coding, communication, ACP, drugs, team planning, training etc

37. GSFDC Training Programme
Assessment Before
Assessment After
Session 1 Training Event
6 Learning Sessions
Session 6 Training & Feedback
Planning
GSF for Domiciliary Care Teams

38. Its about living well until you die www. goldstandardsframework. org
Its about living well until you die