Introduction to the Gold Standards Framework Domiciliary Care Training Programme Maggie Stobbart-Rowlands, Lead Nurse, GSF Central Team

“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.

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.

What does GSF aim to do? 3 Key messages 1.  Improve quality of care 2.  Decrease hospitalisation and cost 3.  Improve cross boundary teamwork + collaboration

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

GSF 3 Steps patients who may be in the last year of life and identify their stage (‘Surprise’ Question + Prognostic Indicator Guidance + Needs Based Coding) current and future, clinical and personal needs (using assessment tools, passport information, patient & family conversations, Advance Care Planning conversations) Plan cross boundary care and care in final days (Use Needs Support Matrix, GSF Care Plan/Liverpool Care Pathway and Discharge Information/Rapid Discharge Plan) identify assess plan

Consultation 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

Three pilot areas Manchester – train the trainers Rotherham – train the workers West Midlands – train the workers 10 agencies in each area 10 carers/agency

P ilot 1 included Head Hands and Heart HEAD - knowledge - clinical competence - ‘what to do’ HANDS - organisation - systems -GSF - ‘how to do it’ HEART -compassionate care -experience of care ’why’ - human dimension-

Pilot Workshop 1 – Hands– identify, assess 4 DVD sessions – Clinical Skills Workshop 2 - Heart

Increased confidence of staff Better communication with other professionals Improved relationships with service users Service development – 1 agency introduced bereavement visits

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

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 Benefits to Patients of Cross Boundary GSF

Reduce hospitalisation 1.Admissions avoidance policy 2.Reduced length of stay- better communication with hospitals – rapid discharge - better turnaround 3.Appropriate admissions criteria 4.Reflective practice as a team 5.Proactive care- coding, communication, ACP, drugs, team planning, training etc

Revised model of delivery Train the trainer 10x 10 Key questions Less head knowledge More focus on hands & heart

Cascade of training Accredited Trainer GSF Carers x 10

Assessment Before Assessment After Train the Trainer 1 6 Learning Sessions Delivered by trainer Train the Trainer 3 & Feedback Planning GSF for Domiciliary Care Teams

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

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

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

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

Evaluation Pre & post Supportive care analysis x 5 Confidence assessment Case study Knowledge test Organisational survey

Trainer evaluation Evaluation of in house sessions Observations Competence assessments Knowledge

Future programmes West Midlands – February Manchester – February Accessing the programme Individual agencies – open programmes – future dates regional centres Commissions – Local Authority, corporates

Its about living well until you die