GSF Acute Hospitals Training Programme Overview Summary   The right care, for the right people, in the right place, at the right time, everytime Overview Summary

1. Why is EOLC important? Quiz How many of your patients are likely to die this year? What will most die from? Where will most die? How many hospital admissions are they likely to have in their final year of life? How many deaths in hospital could be at home? What is the average cost of one admission? Average length of stay in final hospital admission? How often are they likely to see their GP in final year? What proportion of your patients in the final year of life are included on the palliative care/ GSF Register?

End of Life Care in Numbers 1% of the population dies each year in UK – increasing 75% deaths are from non-cancer/ long term/frailty conditions 85% of deaths occur in people over 65 – elderly 56% die in hospital- 35% home (18% home,17%care home) 40-50% of those who died in hospital could have died at home Over 60% people do not die where they choose £3,200- cost of every hospital admission- average 3 / final year £19,000 non cancer, £14,000 cancer - av.cost/pt/final year

GMC Definition of ‘End of Life’ GMC definwww. gmc-uk GMC Definition of ‘End of Life’ GMC definwww.gmc-uk.org/static/documents/content/End_of_life.pdf People are ‘approaching the end of life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with: advanced, progressive, incurable conditions general frailty and co-existing conditions that mean they are expected to die within 12 months existing conditions if they are at risk of dying from a sudden acute crisis in their condition life-threatening acute conditions caused by sudden catastrophic events. End of Life Care Supportive Care Palliative Care Terminal Care Death

Key Messages End of Life Care is important and affects us all Most die of non-cancer/co-morbidity in old age Too few people die at home/in their place of choice Hospital deaths are expensive and often avoidable Everyone has a part to play GSF helps improve quality of generalist care, coordination and reduce hospitalisation GSF is used in the community and can help improve cross boundary integrated care

What if ….Bill Current Ideal Using GSF Identify and code stage Assessment of clinical and personal needs Advanced care planning Planning - regular support + coordination within primary care Handover form out of hours Crisis - discussion with family + GP Admission averted High quality care provided Dies in care home Bereavement care for family Audit (ADA), reflection Continuous Quality Improvement Better outcome for patient, family, staff Most cost effective + best use of NHS In care home – condition worsening Poor quality of life and crisis admissions to hospital Ad hoc visits -no future plan discussed Staff and family struggling to cope No advance care planning, no life closure discussion Crisis- worsens at weekend - calls 999 paramedics admit to hospital- A&E- 8 hour wait on trolley-dies on ward alone Family given little support in grief - staff feel let family down No reflection by teams- no improvement Expensive for NHS - inappropriate use of hospital

What difference does GSF make? Three key messages 1. Quality - Attitude awareness and approach Better quality patient experience of care Greater confidence, awareness, focus and job satisfaction 2. Coordination/Collaboration- structure, processes, and patterns Better organisation, coordination, documentation & consistency of standards Better communication between teams, co-working and cross-boundary care 3. Patient Outcomes – decrease hospitalisation, ACP alignment with patient preferences Reduced crises, hospital admissions, length of stay e.g. halve hospital deaths - more patients dying in preferred place Care delivered in alignment with patient and family preferences  Improve quality of care  Improve coordination, collaboration + cross- boundary care   Improve home care and decrease avoidable hospitalisation Overview

GSF Primary Care and Domiciliary Care Integrated Cross Boundary Care HOME GSF Primary Care and Domiciliary Care HOSPITAL GSF Acute Hospitals CARE HOME GSF Care Homes

patients who may be in the last year of life and identify their stage GSF Key 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 – advance care planning (using assessment tools, passport information, patient & family conversations, Advance Care Planning conversations) care aligned to preferences, cross boundary care and care in the final days identify assess plan

What does it mean to be a GOLD patient ? Good communication between the patient and professionals involved in the planning their care On- going assessment of their clinical and personal needs Living well until they die Dying with dignity in the place of their choice What does being a GOLD patient mean to you?

1. Identify – the right patient GSF Prognostic Indicator Guidance identifying patients with advanced disease in need of palliative / supportive care for register Three triggers: The surprise question ‘Would you be surprised if this person was to die within the next year?’ General Indicators for decline + comfort care/need 3. Clinical indicators Suggested that all patients on register are offered an ACP discussion identify

1. Identify- Needs Based Coding Surprise question Used of Needs based coding Use of Needs Support Matrices A - All - stable from diagnosis years B - Unstable, advanced disease months C - Deteriorating, exacerbations weeks D - Last days of life pathway days Identify stage of illness deliver the right care at the right time for the right patient identify

Lorenzo Alert Electronic Flagging PAS Bedweb System One HCAS EPaCCS Locality Register Lorenzo Alert identify 13

Lorenzo Clinical Content Joy Wharton, Palliative Care Nurse Specialist

Adding an End of Life Alert Record Alert

User clicks on drop down arrow to select alert name

Operation note using clinical note, problems & procedures Clinician completes the onset date, alert description and clicks the green add button to add it to the grid below.

Alert is visible via health issues, inpatient/outpatient pegboards Alert is visible via health issues, inpatient/outpatient pegboards. Information can be used to cite into documents or letters

One piece of information – many uses? Why? Keeps the ship financially afloat Easily accessible information to support audit and improving care agenda Accurate and timely coding Offers clinicians relevant reporting otherwise collected manually One piece of information – many uses? Structured data can alert clinicians of an admission anywhere in the Trust - IPN Improves relations with commissioners Helping to clinically enrich the patient record at a summery level. Quicker treatment at the point of care. timely information to the GP

2. Assess - the right care Assess their current and future, clinical and personal needs Present Future Clinical Personal Assess

Assessment Tools Specific Holistic Many formal assessment tools are available nationally, and locally developed tools within your organisations can be used for all aspects of an holistic approach. Take time to review what is available and to see which type of assessment best suits your organisational need. Assessment Tools fall into two groups: Specific & Holistic. Below are just a few examples of the commonly used tools. Specific Holistic Pain chart or visual assessment score PACA – problem and concerns assessment Body chart PEPSICOLA Doloplus or Abbey Pain scale - for suspected pain with dementia patients Distress Thermometer PAINAD - Pain assessment in advanced dementia Goals of care DS-DT – Discomfort scale

Assessing pain in dementia care Never assume that dementia is the cause of all behaviour that you find challenging - it is a communication/an unmet need - often due to pain/distress Pain is commonly undetected and poorly managed - think physical/pain first Assess - Doloplus/Abbey/DISDAT/Pain-AD

b. Assess personal needs Advance Care Planning Discussion How? Opportunistic informal conversations Formalised systematic What? What matters to you? What do you wish to happen? What do you do not want to happen? Who? Named spokesperson (informal) Can tell those who act in best interests what sort of person you are Lasting Power of Attorney (formal) Can make legal decisions regarding your health Where? Preferred Place of Care Carer’s Preferred Place of Care Other? Special instructions-Organ/tissue donation assess

Advance Care Planning communication Advance care plan ACP

Deciding Right brings together advance care planning, the Mental Capacity Act, cardiopulmonary resuscitation decisions and emergency healthcare plans. At its core is the principle of shared decision making to ensure that care decisions are centred on the individual and minimise the likelihood of unnecessary or unwanted treatment

3. Plan- the right time and place Plan - Cross Boundary Care Think…. Who needs to know about this patient? How will you communicate this? Where will information be documented and stored? Plan

Plan – Care in final days Plan anticipatory ‘just in case’ thinking e.g. drugs, equipment Plan care in final days e.g. using agreed care pathway e.g. LCP Plan support for carers and in bereavement Plan

Benefits to Patients of Cross Boundary GSF assessment & preferences noted Community + others Ambulance + out of hours care – flagged and prioritised Domiciliary care using same coding and planning Community hospitals Acute Hospital GSF patient identified and flagged on system, registered Better planning & collaboration with GP using GSF register If readmitted to hospital - STOP THINK policy and ACP car park free and open visiting Care Home care homes staff speak to hospital regularly 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 care Better assessment + ACP discussions offered Earlier identification of patients in final year of life better provision + access to GPs and nurses prioritised support for patient and carers + easier prescribing coding Collaboration with care home Gold Patients Putting Patients at the Centre of Care Hospices plan

The GSF Acute Hospitals Training Programme: Session Overview Session 6 Session 5 Session 4 Session 3 Session 1 Session 2 Plan anticipatory EOL care for patient and support for carers Overview - bringing it back together - lessons learnt Overview of End of Life Care and GSFAH Programme Why do we need to improve? Identifying the patients nearing the end of life by using needs based coding Assess patients’ and carers clinical and personal needs Plan good cross boundary care to help reduce hospital admissions and length of stay Plan Assess Awareness Identify Embed Care in final days Awareness

The Five GSF Gold GSF Acute Hospital Accreditation Standard 1 - Right people identifying the right patients Standard 2 - Right care assessing their needs clinical and personal Standard 3 - Right place planning coordinated cross boundary care Standard 4 - Right time Proactively planning care including in final days Standard 5 - Every-time Embedding consistency of good practice, extending further and integrating cross boundary care