Transcript Document

Gold Standards Framework in
Care Homes
Nikki Sawkins – GSFCH Lead Nurse
16/07/2015
Plan of session
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Context of GSF in End of Life Care
What are the challenges?
What is GSF in Care Homes ?
Evaluation and Experiences of others
Developments and Plans
Are you interested? – Next Steps
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End of Life care
Do any of your
patients
ever die?
Then you
need to think about
end of life care.
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Clarification of Terms
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End of Life care
• Pts living with the condition they may die from- weeks/months/ years
• pts with advanced disease
• 3 types of pt (cancer, organ failure ,frail elderly /dementia pts )
• ‘Ante-mortal’ care like ante-natal or early life care
Supportive Care
• Helping the patient and family cope better with their illness
• not disease or time specific, ‘less end stage’
• Preferred by some specialists- ‘everyone needs supportive care’
Palliative care
• holistic care (physical psychological, social, spiritual )
• specialist and generalist palliative care
• Some regard as overlapping or following curative treatment
Terminal care
• Diagnosing dying-care in last hours and days of life
End of Life
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Supportive
Care
Palliative
Care
Terminal Death
Care
DEMOGRAPHIC TIME BOMB
• More people are living
longer, with serious
disease and increased
symptom burdens
• Almost double life
expectancy in 100 years
• Increased complexity in
looking after patients
with advanced disease
at the end of their lives
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‘Why are we leaving it to luck?’
Joanne Lynn
“What will we need when we have to live with
a fatal disease?
• We need reliability, We need a care system we
can count on- Doing RIGHT thing at RIGHT time
• To make excellent care routine we must learn to
do routinely what we already know must be done
• All that it takes is innovation, learning,
reorganisation and commitment”
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Added Value 2: Caring for people with non-malignant conditions
and the frail elderly
Function
High
Function
High
Death
Low
GP has 20
deaths per
year
6
2
Other
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Low
Time
Organ failure
Death
5
7
Time
Function
High
Death
Low
Time
Key Factors with end of life
care of elderly
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Multiple co-morbidities
Increasing memory loss/dementia
Difficulty predicting prognosis
Difficulty predicting dying phase
Complex social/ health factors
Need protection from over
intervening - eg DNAR, trolley deaths
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Place of death
Higginson I (2003) Priorities for End of Life Care in England
Wales and Scotland National Council
Place: Home
Hospital Hospice
CareHome
……………………………………………………………………………
Preference 56%
11%
24%
4%
Cancer
25%
47%
17%
All causes
20%
56%
4%
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12%
20%
Gold Standards Framework
3 Programmes of work:
• GSF in Primary Care
• GSF in Care Homes
• EOLC developments and support
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The Gold Standards Framework
A framework to deliver a
‘gold standard of care’
for all people approaching
the end of their lives
A systematic approach to
optimising the care delivered by
healthcare professionals
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A good death for all
“Our aim is that
every person
should be able to
live well and die
well in the place
and in the manner
of their choosing”
But how?
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Gold Standards Framework in
Community Palliative Care
The Aim for Primary Care and
Care Home teams:
to develop a practicebased/care home based system
to improve
the organisation and quality of
care of patients/residents in
the last year/s of life in the
community/care home
So generalist better dovetail
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skills
with specialists
Head Hands and Heart of
Community Palliative Care
HANDS
HEAD
- knowledge
- process/organisation
- clinical competence
- systems
- ‘what to do’
- ‘how to do it’
HEART
-compassion/care
-human dimension-’why’
- experience of care
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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)
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GSF 3 Steps : ……then provide
3. Plan
2. Assess
1. Identify
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5 Goals of GSF
Patients are enabled to have a ‘good
death’
1) Symptoms controlled
2) Preferred place of care
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.
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7 Key tasks/ standards-The GSF 7 Cs
C1
Communication
SC Register and PHCT Meetings, Pt info, PHR,
Advanced care planning (ACP) eg PPC
C2 Coordinator
Key Person, assessment tools eg PEPSI COLA
C3 Control of Symptoms
Assessment, body chart, SPC ,ACP etc
C4 Continuity Out of Hours
Handover form + OOH protocol
C5
Continued Learning
Learning about conditions on patients seen
C6
Carer Support
Practical, emotional, bereavement, National Carer’s Strategy
C7 Care in dying phase-
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LCP / ICP for care in last few days
Underlying assumptions
of GSF
Care for people who are dying is important!
 Most want to give best end of life care –GSF enables
and encourages this
 Developed from primary care for primary care
 Developed and adapted for care homes by care homes -
‘from the bedside not the boardroom’
Raise awareness of dying pts and measures
Framework not prescriptive -Adapt and adoptBecomes standard practice -’this is what we do’
Patient/resident focussed- Proactive- Think of future
needs
 Encourages
creativity and pride in our work
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 National momentum-Share learning and ideas with others
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In hours Proactive Palliative CareAvoidance of crisis-eg GSF/GSFCH
Anticipatory care
helps avoid crises
-improved support for residents,
families + staff
-reduction in hospital/hospice
admissions
(12% reduction in crisis
admissions at EOL - phase 2)
-achievement of preferred
place of care/death
(8% reduction Hospital deaths)
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….and reduce fear
GSF Supported Spread Cascade
National team
SHA, Ca
Network
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GSF
Project
group
Facilitators
Co-ordinators
GSF Spread UK wide
Use of GSF
About 3800 practices – over a third of all
practices in England. Over 80% of PCTs
Over half practices in Scotland, a third in
Northern Ireland, beginning in Wales and
other countries
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So… What do we know?
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GSF Evaluation Nationally
• Better identification and tracking of patients
• More noting+attaining preferred place of death
• Better communication, teamwork and planning
• Fewer crises/admissions
• Better organisation + consistency of standards eg use
protocols, assessment tools, information, bereavement care ,
even under stress
• Better co-working with specialists
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GSF Evaluation Nationally
1.
Attitude, approach, awareness – qualitative factors that
underpin the culture of practice, hard to measure, but often
the most valuable
2.
Processes and patterns of working – practical system
redesign processes that are more structured and formalised
3.
Outcomes – reduces hospital admissions, reduced hospital
deaths, more advance care planning discussions
GSF Evaluation by the University of Birmingham
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GSFCH Care Homes
Planning- 2003/4- GSF adapted for Care Homes
Phase 1 pilot- -May- Dec 04
• 12 care homes in 6 areas
• Report March 05
Phase 2 pilot-June 05- Feb 06
• 100 care homes with 35 facilitators-18 /28 SHAs
• Research study Birmingham University funded by Macmillan
Phase 3 Programme -June 06- Feb 07
• About 250 care homes – 3 bases –Crawley phase 3a
• Continuing evaluation
• Phase 3b – Crawley and Phase 4 Programme June 07 –March 08
Open and Commissioned areas.
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Stage I Preparation
Stage II Training
Stage III Consolidation + Sustainability
3-6 months
4 workshops in 9 months
9 – 12 months
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Enrolmen Awareness
Raising
t of Care
Meeting
Homes
Local
ADA
Before Coordinator
s Meetings
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Workshop
1
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Workshop
2
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Workshop
3
Workshop
ADA
4
After
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Ongoing
ADA
Final
Appraisal
GSFCH
Accreditation
Gold Standards Framework in
Care Homes - GSFCH
Aims
1.
To improve quality of end of
life care
2. To improve collaboration with
primary care and specialists
3. To reduce admissions to
hospital in the last stages of
life
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Context
• Half a million people live in Care Homes-about 1%
Approx 20% people die in Care Homes
• 86% all deaths in people over 65, 51% in people over 80
For every NHS bed, there are 3 Care homes beds
• The sector employs about 1.2 million people
• People stay on average 2-2.5 years in Nursing Homes
• An average N. Home with about 30 beds might expect
about 1 death/ month, or about a third/quarter
turnaround /year
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“ If you are old and in a care home,
you know you are probably going
to die quite soon. Most older people
don’t think that dying is a tragedy,
though they do think that dying with
unresolved issues is.”
Prof Ian Philp
National Director for Older people
The Times Sat 3.6.06
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End of Life CareGetting it right
They’ll never
forgive you
if you don’t
They’ll never
forget you
if you do
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Experience of GSF
in Care Homes
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Attitudes, awareness and approach
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Patterns of working, structure/ processes
eg confidence all staff, care needs focus,
proactive care
eg communication all staff, recording, information
sharing
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Outcomes
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eg more advance care plans, fewer crises,
better quality of dying, staff feel valued
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Does using GSF help patients
with end of life care needs in
care homes?
It helps coordination and communication
It helps confidence of staff
It helps us focus and measure
It helps kick start changes
It helps specific things like needs based
coding, Advance care plans, anticipatory
prescribing, communication with GPs etc
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Y E S
GSFCH Open Programme Plan
Phase 4 -Walsall
ADA
ADA
Preparation
July 2007
Introduction
Consolidation
consolidation/embedding
…………..First gear………….Second gear………..Third gear……….Fourth gear
Workshops
26 Sept 07
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5 Dec 07
27 Feb 08
7 May 08
Four Gears
1. Getting going
1.
2.
3.
Coding, Register
Meeting,
Coordinator
2. Moving on
1.
2.
3.
Assessment of symptoms
+ Advanced care Planning
Out of hours continuity
Education and reflection
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3. Gaining Speed
1. Education and reflection
2. Carers and family support
Bereavement (and staff)
3. Care in Final days
4. Cruising
1. Sustain
2. Embed
3. Extend
Phase 4 Evaluation
1. After Death Analysis – Electronic
Format – Register on line
– Background information
– Last 5 patient deaths before and after
GSF introduction
– What went well, what didn’t go so well,
what could we do better.
– Feed back of information.
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Online After Death Analysis
(ADA) Audit Tool
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Networking and speed-dating
• Sharing experiences with others – key to
learning,finding solutions to some of the
challenges, sharing good ideas, handy hints.
• Eurekas ‘Things that have worked for us……’
• ‘Speed dating’- capturing specific topic
issues
• Good Practice Guide – shared learning and
experience
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SO WHAT!
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Reactive patient journey-
MR B in last months of life• Care Home –no discussion wishes for end of life (only
burial/cremation) -no PPOC discussed or anticipated
• Problems with symptom control-high anxiety
• Crisis call eg OOH-no plan or drugs available - GP sent
ambulance
• Admitted to hospital – disorientated.
• Dies in hospital ?over intervention/medicalised
• Carer support in grief by care staff
• No reflection/improvements by care home/GP
• ? Inappropriate use of hospital bed
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GSF Proactive pt journey-
Mrs W in last months of life
• Coded on Register-discussed at Care Home GSF meeting
• Focus of care at stage of life
• Regular discussion and planning with care home/GP/SPC - proactive
care
• Assessment of symptoms -referral to SPC-customised care for
resident
• Carer involvement in care/decision (residents wish)
• Advanced Care Plan completed with resident and family - Preferred
place of care noted and planned.
• Handover form issued –ACP wishes – anticipatory drugs issued in
care home
• End of Life pathway/LCP/protocol used
• Pt dies in preferred place- the care home fully supported by well
trained staff. Bereavement support – for all .
• Staff reflect-ADA and SEA - audit gaps improve care, learn
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GSF and GSFCH is part of the
jigsaw
GSF/GSFCH is part
of the jigsaw to
enable proactive
end of life care for
all.
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GSF and Prognostic Indicator
Guidance
• Development of a
Prognostic Indicator
Guidance paper – PIG, in
consultation with national
leads and organisations
• More challenging
identifying patients with
non-cancer for SC register
• Evaluation shows that 60%
of practices are including
non cancer patients on the
GSF registers within 12
months of implementation
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GSF - Advance Care Planning
GSF template includes:
Gold Standards Framework and the Supportive Care Pathway Draft 7
Thinking Ahead - Advance Care Planning
• Thinking ahead
- open questions
- what matters to pt / carer
- what to do and what not
to do
Gold Standards Framework Advance Statement of Wishes
The aim of Advance Care Planning is to develop better communication and recording of
patient wishes. This should support planning and provision of care based on the needs and
preferences of patients and their carers. This Advance Statement of wishes should be used
as a guide, to record what the patient DOES WISH to happen, to inform planning of care.
This is different to a legally binding refusal of specific treatments, or what a patient DOES
NOT wish to happen, as in an Advanced Decision or Living Will.
Ideally the process of Advance Care Planning should inform future care from an early stage.
Due to the sensitivity of some of the questions, some patients may not wish to answer them
all, or to review and reconsider their decisions later. This is a ‘dynamic’ planning document
to be reviewed as needed and can be in addition to an Advanced Decision document that a
patient may have agreed.
Patient Name:
Trust Details:
Address:
DOB:
Hosp / NHS no:
Date completed:
Name of family members involved in Advanced Care Planning discussions:
• Proxy - who else involved (LPOA)
Contact tel:
Name of healthcare professional involved in Advanced Care Planning discussions:
Role:
Contact tel:
• Who to call in a crisis
• Preferred place of care & death
• Other requests eg organ donation /
special instructions
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Thinking ahead….
What elements of care are important to you and what would you like to happen?
What would you NOT want to happen?
ACP Dec 06 v 13
ACPs in care Homes
• Improved communication with residents and
families early on
• Improved planning of care
• Reduced crises
• Helped formalise discussion using a tool
• Some gave to families, some senior nurses
• DNAR difficult- prefer ‘Allow Natural death’.
• Some found they were difficult discussions
• All liked having them – useful and clear
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Difficulties with ACPs
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Bring up the subject
Communication difficulties
Discussing options- ?unrealistic
DNAR discussion
Family tensions
Staff resistance
Updating them
Communicating them
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How do we cascade the
information? - GSF Website
• 800 hits per day
• Information on GSF,
resources and new
developments
• Links to the online audit
tool
• Plan to update for Autumn
07 with protected sections
for registered practices,
care homes and PCT
facilitators/SHA leads
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For more information on GSF
National GSF team – Judy Simkins - GSF / GSFCH Administrator
Tel: 0121 465 2029
GSFCH LEAD Nurse - Nikki Sawkins [email protected]
Email:
• [email protected]
Website:
• www.goldstandardsframework.nhs.uk
NHS End of Life Care Programme
• www.endoflifecare.nhs.uk
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