What makes a good KIS?

Carey Lunan GP, Edinburgh Access Practice (homeless) ACP Clinical lead Edinburgh CHP

the right person the right time the right message with consent (ideally)

KIS background and update

Original remit sGMS requirements Rollout Uptake

So what determines impact?

• The right patients • The right information • Looked at by the right people • Facilitated by the right support

The right patients: who most benefits?

Those who can’t communicate Those likely to present to unscheduled care Those with complex care needs – Frail elderly, mutimorbidity – Long term conditions – Palliative care needs – Frequent attenders to ED

The right patients: how to identify?

SPARRA – useful guide (now online) Clinical judgement SPICT http://www.spict.org.uk/ MDT working Frequent attender data BOXI reports

The right patients?: a local audit Wider breadth of conditions post KIS 2013: 86% of ACPs for patients in CHs 2014: 50% of ACPs for patients in CHs

The right information: a quality KIS “

What information would I want to know about this patient if I was the doctor seeing them out of hours?”

Examples of useful information • Baseline functional status • Baseline clinical status • Level of cognitive impairment / capacity issues • Behavioural issues

More examples of useful information • What tends to precipitate deterioration • Threshold for admission • Ceiling of therapy • Specific patient/carer wishes

Aim for your ACP to be: • specific • succinct • accurate • unusual!

Try to avoid non-specific phrases such as… “usual care” “treat in nursing home if possible” “admit / discharge as directed by presentation” “treat as appropriate” “gonnae no dae that”

And obvious phrases such as….

“If develops infective exacerbation of COPD, treat with antibiotics and steroids…”

Far more useful might be….

“Patient has severe COPD with self management plan in place. Is aware of when to start antibiotics and steroids. Has developed steroid-induced psychosis in past, requiring haloperidol. Patient/carer will contact OOH if condition worsens or if concerns.”

The right information?: a local audit 20 volunteer practices, 60 ACPs analysed Assessed using established criteria and a qualitative question ““

In your clinical opinion, is the content of this ACP helpful in providing out of hours care?”

Quality criteria used • Evidence of KIS being reviewed in the last 3 months?

• Documentation of current clinical status?

• Documentation of current functional status?

• Documentation of full next of kin details?

• Documentation of other healthcare professionals involved?

• Only relevant information included in past medical history section?

• Documentation of preferred place of care?

• Documentation of whether or not CPR has been discussed?

• Documentation of CPR decision?

• Evidence of self management plan?

Audit findings: • Higher quality of ACPs post KIS 2011: 33% judged as useful 2014: 90% judged as useful • Specific feedback & recommendations offered

Audit recommendations: • Inclusion of full next of kin details • Editing of past medical history section • Clear documentation of when last reviewed • Avoidance of duplicate freetext information • Examples of useful information to include

The right people accessing KIS?

• Working well in OOH setting • Local (peer discussion, SEAs) and national (KIS evaluation) data show that secondary care access remains very low

The right people accessing KIS?: local approaches • Development of training resources • Meeting key clinicians • Included in induction packs • Audit of acute admissions • Interface groups • Review of discharge letter process to include KIS • Shared across boards

Some specific challenges?

• Time • Consent • External ACPs

Time….

• sGMS requirements – 15/1000 high risk patients – quarterly review of relevant patients • Practice systems – “GP-lite”; consider admin lead – RFC in progress for improved print out – Patient information leaflets – Proactive consent?

Consent… • KIS is an OPT-IN system requiring explicit consent • In exceptional circumstances a KIS can be sent without consent - generally for CAPACITY or SAFETY reasons: – Vulnerable adults – Vulnerable children – Risk to self – Risk to others

External ACPs… Option of KIS-compatible Word doc  Clinical mailbox  Cut and paste into KIS

Other challenges • Ageing population and the increasing need for anticipatory care • Normalising end of life conversations • More reactive, proactive social care • Adequate resourcing of primary care

Other challenges • Investment in IT systems and support • Investment in and support of primary/secondary care interface working • Ethical and practical challenges of information sharing between health and other sectors

Ideas for quality improvement?

• Practice audit of ACP quality using established criteria (appraisal QIA) • Input from relevant others – share workload • Wider sharing of SEAs related to KIS ACPs • Feedback through LMC and interface groups