1. Improving End of Life Care in Care Homes using GSF Lucy Giles Clinical Nurse Advisor The National GSF Centre in End of Life Care The leading EOLC training centre enabling generalist frontline staff to deliver a ‘gold standard’ of care for all people nearing the end of life

2. Context- Why is End of Life Care important? Source: Government Actuary Department 2004-based Projections for the UK +17% -8% Projected Gomes and Higginson 2008

3. 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  Approx 80% care homes residents in final year of life  Approx 30% hospital patients are in final year of life  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

4. Elderly 'dying undignified death' “Many elderly fear being left on a geriatric ward to die. Many elderly people are left without proper palliative care and end up dying undignified deaths, a survey suggests.” BBC News 11 April 2006

5. 50% of frail care homes residents could have died at home NAO report Nov 08

6. DH End of Life Care Strategy July 08 4.30 (p 91) “Inadequate training of staff at all levels within care homes, sheltered housing and extra care housing sector..is considered to be the single most important factor” Factors leading to suboptimal care – Lack of ACP – Inadequate recognition and holistic assessment – Death concerns – Impact on other residents – Inadequate access to NHS services – Inadequate medicine reviews – Training

7. ‘Win-win’- saving money and helping people die where they choose Context in care homes study in 1 PCT over 1 month Source: National Audit Office/RAND analysis (2008) A quarter of care homes residents deaths occurred in hospital 40% of those had no medical reason to be in hospital – 1500 bed days (£250/day) = £375,000 in 1 month = £4.5m/year It is estimated that by reducing hospital bed days by 10% and av. length of stay by 25% - £104 million could be redeployed to support dying in usual place of care in community Education alone in care homes doesn’t work- need change management skills to embed new system plus supported learning (Froggatt et al)

8. Cost effectiveness £3,200- cost of every hospital admission- average 3 / final year What could you buy for 1 saved admission ? People + Services – D. Nursing / home care Training eg GSF = 1-2 care homes full 1 year GSF training or 5 GP practices Expenditures Life span

9. Patient Choice - preferred and actual place of death NOTE Most people die in hospital though evidence confirms that most would prefer to die at home

10. Care closer to home Reducing hospitalisation Advance care planning discussions Needs Based Coding Needs Support Matrices Planning meetings Team collaboration DNaR/ AND discussions Training and education for all staff (including night staff and temp/ bank) Policy +guidance on reducing avoidable admissions Stop Think policy Anticipatory prescribing OOH handover form Audit/ SEA LCP for dying Communication with family re ACP

11. Communication summary Contact -Effective means of communication –GP Practices including these residents on their palliative care/GSF registers, meetings, emailing coding. Coding - proactive care using the needs based coding of residents, reviewing together the Needs Support matrices Proactive planning and regular visits to the care homes, especially focussing on those in the C and D codes/ yellow and red, personal lists coded etc,

12. Reduce hospitalisation 1.Admissions avoidance policy 2.Reduced length of stay- 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

13. Agreement on protocols and policies in the home use of care pathway for the dying (eg LCP), DNAR forms, decreasing hospitalisation policies, when is it appropriate to call GPs, out of hours providers, Verification of death, advance care planning discussions, discussions with relatives etc

14. Better Together GPs/DNs and care homes Communication – Contact -. – Coding - Needs Support matrices – Proactive planning Crisis admission Prevention – Reducing hospitalisation – Continuity 24 hours – Anticipatory prescribing Collaboration – Agreement on protocols – Reflection- – Informal discussions-

15. Undignified dying Over 50% of people still die in hospital, many in transit or A&E, but most say they want to die at home.

16. At individual Level - Bill Proactive planning 82 year old in care home -COPD, frailty+ other conditions 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 Unacceptably poor level of care especially for the elderly

17. What if ….Bill Current Ideal 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 Using GSF Care Homes Identify and code stage Assessment of clinical and personal needs Advance 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

18. GSF Five Standards Right person –identifying the population, communicating this to others Right care – assessing needs, preferences and care required + providing services Right place – reducing hospitalisation enabling more to live and die at home Right time – proactive planning, fewer crises, predicted care in final days of life Every-time – consistency of practice

19. The GSF Package has many tools Pt need s Suppor t from hospital /SPC Support from GP Year s Mon ths Wee ks Day s Prognostic Indicator Guidance After Death Analysis - ADA Advance Care Planning – Thinking Ahead Needs Support Matrix GSF Care Plans Help populate EPaCCS / Locality Registers Passport Information New GSF IT Solutions and e-PIG New Virtual Learning Zone Needs Based Coding

20. Underlying themes to optimise care Pre-planning of care – Coding, ACP, planning meetings, GP collaboration, Anticipatory Rx, handover form, LCP protocol Communication – listening, talking + recording Team Working – within care home, with GPs and with others Clinical care – Assessment and management Decrease hospitalisation – Admission avoidance, decrease length of stay, rapid discharge

21. Decreased hospital admissions and deaths with GSFCH Training programme as measured by ADA phases 4-6

22. 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

23. And the impact

24. Improving End of Life Care with GSF Head Hands and Heart HEAD Evidenced-based knowledge, clinical competence ‘what you know’ HANDS Systems minded care coordination ‘what you do’ HEART person-centred compassionate care ‘the way you do it’

25. 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

26. GSF enables a gold standard of care for all people nearing the end of life 1.Spread 2. Depth Quality assurance Foundation Level then Enhanced Level to QR Accreditation e.g. Primary Care and care homes 3. Joined-up GSF Quality Improvement provides full package of support for all settings Integrated Cross boundary care GSF can be a common language