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Vanguard learning guide EHCH element 4.1

High-quality end of life care

This is a live document: Version 1.1 29/06/2017



Contents What do the ‘vanguard learning guides’ do? 3

What is end of life care? 4

How does it contribute to the EHCH care model? 5

Ambitions for Palliative and End of Life Care 7

Characteristics of good care when a person is dying 8

Vanguard service models: how vanguards are delivering this element of the EHCH framework 9

Before you start… 14

Benefits and impact 15

Roles and relationships 17

Learning and development tips 18

Measuring success 19

Things to consider 20

Challenges and solutions 22

Materials to support your implementation 23

Your ‘to do’ list 26

Acknowledgements 27

Contents and

introduction

About end of life care

Benefits and

impacts

Learning and development

tips

Measuring success

Materials to support

you

To do list and

thanks

Before you start

Roles and relationships

Vanguard service models

Things to consider

Challenges and

solutions



What do the ‘vanguard learning guides’ do?

• Focus on a key element or sub-element of the Enhanced Health in Care Homes (EHCH) care model.

• Identify interventions put in place by the enhanced health in care home vanguards that have worked particularly well, and which could be readily replicated at clinical commissioning group (CCG), local authority, Sustainability and Transformation Partnership (STP) and/or regional level.

• Reference learning from relevant good work going on outside of the vanguards, where it is improving the lives of care home residents (includes residential, nursing and other settings).

• Describe a step-by-step approach to support implementation in non-vanguard areas, including first steps, roles and responsibilities, things to consider and the resourcing and benefits associated with these interventions.

• Support a consistent implementation of the core elements of the EHCH care model.

• Include practical materials such as job descriptions, referral criteria and operating models that can be easily adapted and adopted by other areas.

• Set out the key practical challenges arising from implementation of the care model, together with learning from the vanguards to help you overcome them.

• Link to national guidance and NHS England’s series of ‘Quick Guides’ where relevant.

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People approaching the end of life

• Most (but not all) care and nursing home residents are in the last few years of their lives.

• In this guide we refer to people as approaching the end of life when they are identified by health and social care staff as 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:

(a) advanced, progressive, incurable conditions,

(b) general frailty and co-existing conditions that mean they are expected to die within 12 months,

(c) existing conditions if they are at risk of dying from a sudden acute crisis in their condition,

(d) life-threat.

End of life care

• End of life care is care that helps all those with advanced, progressive, incurable illness to live as well as possible until they die.

• It enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement.

• It includes management of pain and other symptoms and provision of psychological, social, spiritual and practical support.

What is end of life care?

Source: The National Council for Palliative Care / Dying Matters / NHSE End of Life Care programme

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introduction


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Things to consider

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How does high-quality end of life care support the EHCH care model?

• This vanguard learning guide focuses on sub-element 4.1: High-quality end of life care (EOLC).

• Individuals who are approaching the end of their life often experience profound physical and emotional changes.

• High quality end of life care ensures that people are cared for and die in the place of their choosing, with dignity and in comfort.

• Care home residents have the same entitlement to these types of high-quality holistic health and social care as those living in their own homes and in hospital.

• Providing effective palliative care and end of life care should therefore be a priority for the whole of the local health and care system, irrespective of whether the individual is in a nursing home, residential home, extra care or their own home.

• This guide can be most usefully considered alongside our learning guides on: 1.1 Aligned GP services, 2. Multi-disciplinary team (MDT) support for care homes, and 4.2 High-quality dementia care.

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Name of Intervention • High-quality end of life care (EOLC) in care homes.

Description of intervention • A systematic, proactive approach to identify residents who may require end of life care.

• Individuals supported to die in their place of choice, using advance care planning, personalised care plans, and treatment escalation plans.

• Where possible, an Enhanced Health in Care Homes (EHCH) care model should use digital tools to enhance the quality of end of life care. The use of electronic palliative care coordination systems (EPaCCS), e.g. Coordinate My Care which is used in London, or other local solutions, and enhanced Summary Care Records all help facilitate better care coordination.

• Care home staff are supported with education and training on palliative care knowledge and skills. This is incentivised through both contracts and partnership working and delivered in collaboration between social care providers, NHS, local government and the voluntary and community sectors.

• Education for family members and communication to keep people informed and with clear expectations about and involvement in care planning.

• Services should address the needs not only of the individual themselves but also of their family, their carers, other care home residents, and the staff who support them. This should encompass care both before and after death, including sensitive personal care after death, verification and registration, and high-quality and personal support for those who are bereaved.

• End of life care is delivered using a partnership approach, including not just GPs, social workers and social care providers but drawing upon knowledge, capacity and skills from acute hospital, hospices and community nursing teams.

High-quality end of life care in care homes

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Ambitions for Palliative and End of Life Care

A national framework for local action 2015-2020

Source: National Palliative and End of Life Care Partnership www.endoflifecareambitions.org.uk

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http://www.endoflifecareambitions.org.uk/



Characteristics of good care when a person is dying

The Priorities for Care of the Dying Person

• Priority 1 - this possibility [that a person may die within the next few days or hours] is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly.

• Priority 2 - Sensitive communication takes place between staff and the dying person, and those identified as important to them.

• Priority 3 - the dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.

• Priority 4 - the needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible.

• Priority 5 - an individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion.

Source: One chance to get it right: Improving people’s experience of care in the last few days and hours of life, Leadership Alliance for the Care of Dying People

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Service model and resourcing used to fulfil EHCH framework:

• A Head MacMillan nurse aligned to a specific care home.

• 32 Care Homes supported by six MacMillan nurses, who are able to support staff and liaise with families.

• Previously experienced lots of calls made by agency and out of hours (OOH) staff, so have developed an ‘information box’ with a signposting leaflet and other materials to familiarise temporary staff quickly with where to obtain advice and guidance.

• Using templates on EMIS to identify people with chronic diseases who may be approaching end of life.

• Training rotates across five homes at a time based on geographical location, and incorporates an end of life dying document.

• The vanguard is auditing deaths in care homes to understand how current provision meets needs.

• Encouragement for care home staff to join foundation courses for training.

Learning and evolving the service:

• Good outcomes so far - not one person within the 32 care homes in scope has died in hospital during the first year.

• Last year funded AGE UK for a ‘No one dies alone’ pilot. Evaluation findings were that the service was not needed, as local care home staff manage well already.

• Now funding a bereavement service – open to family and staff.

Vanguard service models – Newcastle Gateshead

Lessons learned:

• Establish an effective template for recording end of life needs, through meetings with registered GPs.

• Standardise the format of how practices and wider staff discuss end of life care at MDT meetings.

• Would encourage other areas to establish a care home palliative care link group.

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Service model and resourcing

• A lead Community Specialist MacMillan care nurse is based in the area’s hospice.

• Senior nurse goes into care homes providing support for advance care planning.

• Education for care home staff is provided to and by the multi-disciplinary team.

• An end of life care facilitator works with acute trusts to support patients to be discharged back to care homes.

• Wakefield CCG and partners have implemented a single point of contact for end of life across the area and coordinate across both community and care home settings.

• The health and social care system has also developed a end of life care network of organisations and people to develop services, across the whole health and care system.

• The CCG leads on managing this network and has employed a dedicated project manager for this purpose: bringing individual organisations together, and encouraging peer-to-peer learning and greater co-ordination.

Learning and evolving the service

• Working to introduce effective signposting towards the range of commissioned and community support available.

Vanguard service models – Wakefield

Lessons learned:

• You need to remember that patients aren’t always in the ‘right place, right time’ – the service needs to be flexible to meet their needs rather than other way around. The service should be people orientated.

• For Wakefield a single point of contact for end of life care has proven most effective.

• One sheet captures a person’s wishes at end of end of life care (palliative care). This is then uploaded to EMIS. This approach is being piloted in 19 care homes, and it is hoped that it can help overcome difficulties in embedding and supporting EPACCs use with GPs.

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• 20 Nursing Homes, 11 residential homes & 50 learning disability homes.

• 80 percent of residents dying in their preferred place of death.

• Identify residents in the last year of life through prognostic indicators – Clinical review by a clinical nurse specialist in palliative care, complex EOLC needs joint working with local hospice.

• Palliative Care Meetings in the GP practice that medically support care homes are attended by the supportive care home team to ensure patients in the last year of life are on the agenda and plans of care in place.

• End of life care plans for care home residents are shared with Out of Hours service through an electronic patient record (EPaCC) – Coordinate my Care (CMC).

• Key Performance Indicators are used to develop outcomes.

• Developed EOLC tools.

• Development of new Sutton EOLC Strategy – care homes key in the strategy.


• Piloting a model of end of life care in learning disability homes.

• Piloting new IG toolkit to allow access to NHS mail and Coordinate My Care tool.

Vanguard service models – Sutton

Lessons learned:

• Relationship building is key.

• Adequate resources need to be available.

• Clear end of life care pathways in place for care homes.

• Change management takes time.

Training tips:

• Sutton provide training around their end of

life care pathway – bespoke to each home.

Education

GP – Palliative Care Meetings

Clinical Rounds

Model of EOLC in Sutton Care Homes:

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• Recently launched a pan-Lancashire strategy for end of life care which includes care homes. GP quality framework also references end of life care.

• One-of the monitoring indicators is no of patients with advance care planning.

• A specialist nurse practitioner, working on a locality basis, visits care homes and supports admission avoidance, advance care planning and comprehensive geriatric assessment.

• Focusing on chronic long-term condition management , and those who may be in last year of life.

• Care home EOLC and education forum developed by Hospice.

• High quality EOLC and palliative care training and have developed an education directory.

• Communication skills courses offered at 3 levels – basic, intermediate and advanced, to care homes.

• Care home telemedicine and 24hr phone line available (see next slide).

Vanguard service models – Airedale/East Lancashire CCG

Lessons learned:

• MDT approach essential.

• Consistent and standardised understanding and use of ACP documentation.

• Need robust processes in place for sharing of documents.

• Engagement with out of hours care and health providers is vital.


• Ribblesdale Locality, in East Lancashire to be a pathfinder for Age UK End of Life Care Pathfinder with the aim of reducing the need for unplanned admissions. Focused on identification at primary care level, ACP, MDT care co-ordination, wrap around support and bereavement support.

• A Pilot project with Pendleside Hospice to provide an end of life education and support programme for care home and domiciliary care homes across 3 localities in East Lancashire. Pilot also works with the acute trust to examine the frequency of emergency department attendance and emergency admissions from care homes, for patients identified as being at end of life.

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• The Gold Line is a 24/7 telephone service for people in their last year of life.

• Run by nurses, this innovative service provides care and support for terminally ill patients and their families across Airedale, Wharfedale, Craven and Bradford.

• The care provided by the nurses running the helpline and the services they coordinate has meant that a significantly higher proportion of people have been able to die in the place of their choosing (usually at home) than the national average.

• It forms part of Airedale’s Digital Care Hub, a 24/7 clinical hub which provides teleconsultation for a range of settings: prison health care; care at home; nursing & residential care; supporting end of life patients.

• Further information is available at: http://www.health.org.uk/gold-line

Vanguard service models – Airedale/East Lancashire CCG

Why implement a ‘Gold Line’ model:

Vulnerable group of patients and carers especially ‘out of hours’.

High risk of hospitalisation, sometimes avoidable.

Urgent care services not configured to manage these patients, confusing array of teams to call.

Need for advice/reassurance only.

Support whilst waiting for services to attend.

Help patients to achieve their preferred place of care and death.

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http://www.health.org.uk/gold-line







Before you start…

Understand what services are already in place

Think about data and metrics Don’t forget to involve wider

partners

• Map what staff need to know and do in CCGs, Care Homes, Acute Care, Primary Care and the voluntary sector.

• Clear guidance and a shared understand can help reduce unnecessary admissions and support discharge / dying in place of choice.

• Map existing education and training provision.

• Discuss commissioning intentions with commissioners across health, social care and the voluntary sector, as well as with the ambulance service, acute and community health sector and care and nursing home providers.

• Identify the metrics you want to use:

o No of people with advance care plans

o No of people on end of life care register

o Service user experience

o Staff experience

o Achievement of preferred place of death (PPOD).

• Work as a whole system to obtain data on where deaths are happening and look at how data is being captured.

• Be honest and up front about any historic or ongoing issues around implementation of EPACCs, and look at what is feasible given the IT systems in place currently and in the near future.

• Identify your stakeholders, including the ambulance service and social care.

• Think about the roles of local community and voluntary sector organisations, for example MacMillan, Age UK, Dementia UK and Marie Curie.

• Recognise the role of hospices in local EOLC provision, and the expertise their staff can share.

• Engage with community pharmacy given the role of medicines and pain-relief in end of life and palliative care.

• Use the experiences and views of carers’ groups, patients and families to shape your view of what good looks like for your area.

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“How people die remains in the memory of the people who live on” Dame Cicely Saunders – founder of the modern Hospice movement.

Benefits and impact for individuals and families

• Understanding and planning for the rest of your life – being supported to live the rest of your life until you die. An opportunity to meet needs holistically across mental and physical health and help people attain their goals.

• Improved quality of life – through better symptom control as a result of co-ordinated, informed care. People are less likely to be subject to treatments of limited clinical value.

• Care and death in your preferred place of care - helps patients at end of life to remain at home or in their preferred place of care, and to die in their usual place of residence.

• Improved patient experience – more individualised and personalised care through care planning, and greater continuity of care as a result of co-ordination of care across health and care professionals and settings.

• Improved family experience – and a greater opportunity for quality time with the person.

• Support for systematic advance care planning to recognise choice and control – empowering people to make decisions on how they want their end of life care to look e.g. plans for escalation.

• Support for carers and families around bereavement, including better recognition of people’s wishes and cultural aspects after the person has died, through improved planning for the immediate aftermath.

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For staff:

• A co-ordinated approach to end of life care means that more patients are flagged to professionals and can be identified as potentially in the last year of life and receive appropriate care in response.

• If staff across care homes and supporting health and voluntary services plan carefully with individuals then it can reduce amount of time person comes into contact with acute services (if that’s what they want).

• When end of life care and conversations are planned and well-thought out, staff can plan appropriate end of life care rather than deal with a series of crises.

• Support GPs to identify people who are likely to die within the next year (or more, in the case of people with dementia) and include them where appropriate on palliative care registers.

For health and social care systems:

• More choice and well-organised community support can reduce the numbers and cost of unnecessary hospital admission (final 3 months average over £4500 per person who died1), and improve people’s experience of living and dying wherever they are.

Benefits and impact for staff and organisations

Source: Nuffield Trust: Exploring the cost of care at the end of life, September 2014

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From perspective of health

• It is important to remember that care homes and hospices are independent organisations with their own goals and drivers.

• You must engage from a starting point of ‘working with, rather than doing to’ – or else your initiatives will struggle.

• It is a key responsibility for commissioners to pro-actively facilitate engagement across the system – including with ambulance trusts and the acute sector.

• Think about levers and influences – engage with social services and quality team to get on board so they’re aware of what quality end of life care looks like and can inform your plans for the future.

• For care home staff it is important to consider multiple options for embedding EOLC knowledge - having champions for EOLC is a good approach but may not work for every home – provide and co-develop options.

• Be realistic – you will need to develop relationships over time, and building trust from a starting point of shared respect is the right approach to embed amongst visiting health staff.

• If relationships between care providers and commissioners are less well developed, think about working with those individuals in the local system who are known and trusted by care homes in your area, for example voluntary groups, local CQC representatives, and GPs.


RELATIONSHIPS are key

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Learning and development tips • Anything that simplifies or de-mystifies advance care planning is welcome – for care homes staff,

carers and families and also for ambulance services.

• Be clear on what needs to be signed by whom, and what should be adhered to. For example a DNACPR can only be signed by a doctor (or in some situations, a fully trained nurse). It doesn’t need to be signed by the resident, but some patients may like to countersign it. It can’t be signed by a family member or any care home staff. However involving the resident who has mental capacity, family members and care home staff in the discussions is good practice.

• This is a sensitive area and can be uncomfortable for staff - build on those informed and knowledgeable staff who are most interested.

• Empower care home staff to allow them to make changes and help change culture in the home towards a more pro-active, open, planned approach to end of life care.

• Use role modelling to support training and education – consider providing an education training session in a care home – short & sharp – then follow up with clinical round – reinforcing what has been taught – and then follow up and check knowledge in next round. Staff can then see how clinical specialists deal with challenges and learn from them.

• Take families on the journey with staff – educate and raise awareness amongst family and carers of what to expect – both in terms of care and support.

• Try to raise the profile of the staff in care homes so colleagues know how to support them.

• Support acute and ambulance providers to recognise that care home staff know their residents well so when they raise an issue, it’s valid and a response is more often than not required.

Examples:

• East Lancashire – systematic learning for care home staff around use of telemedicine and end of life care plans including responding to Do Not Attempt Resuscitation (DNACPR)

• Learning and support for carers available in East Lancashire.

• See the job description for an end of life Champion role in a care home from Sutton online

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Why is this important? • To ensure the service is actually benefitting patients and ensuring that they are able to die

with dignity, in their preferred place of death, with both the individual, care home staff and families/carers informed and empowered throughout the last year of life.

• Commissioners will want to see the clear cost/benefit for EOLC schemes as well the positive benefits for quality of care and quality of life.

• Strong and robust evaluation of impacts can help ensure that services are mainstreamed over the long-term.

Potential metrics to consider • No of people identified.

• No of people dying in preferred place of death.

• Time spent out of hospital in the last 3 months of life

• No of advance care plans.

• Learning and development options available to care providers and take up.

• Qualitative evaluation post bereavement – remembering to get feedback from patients and carers at appropriate time e.g. using questionnaires.

• It is important to work with your acute trust and ambulance service to get a true picture of place of death, underlying cause of death, mortality and deaths in your area. Datasets such as Public Health England (PHE) Fingertips website – end of life care profile, can also provide aggregated information and help with benchmarking.

How can you tell if you are successful?

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Things to note:

• Whilst it is easier to measure where somebody dies, recording the ‘preferred’ and actual ‘place of death’ alone doesn’t reflect the quality of the care and experience, or whether the person’s other, potentially more important priorities have been addressed.

• It is important to ensure that you work with staff, residents receiving end of life care, and families to get a rounded picture of whether or not the changes your area is implementing are successful.

http://fingertips.phe.org.uk/profile/end-of-life







Things to consider as you implement

Effective partnership working Care planning and advance care planning

• This must be a process led by both providers and commissioners.

• Developing an effective aligned GP service and pro-active GP, nurse or advanced nurse practitioner ward rounds can help in terms of supporting care home staff with end of life care and advance care planning.

• Recognise GP time, interest and input is varied – not mandated – build on those who are willing.

• Think how your area can better link up with NHS 111, including the forthcoming rollout of *6 for care homes.

• Use of tools such as ‘Forget me Not’, ‘Coordinate My Care’ and ‘This is Me’ – can be very helpful.

• Make a distinction for people with capacity and without – with dementia prevalence rates increasing rapidly amongst care home residents this is increasingly important.

• Work as a multi-disciplinary team (MDT) to be clear on what can be done for those without capacity – e.g. a best interests approach.

• Follow the Mental Capacity Act in implementing any agreed care plan or advance care plan.

• A MDT team approach to care planning will get the best results.

• See our Dementia vanguard learning guide for more information.

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https://futurenhs.kahootz.com/connect.ti/carehomes/view?objectId=9277968



Things to consider as you implement

Supporting carers, family and wider networks

• Consider working with your local Acute Trust or Ambulance Service to raise awareness and provide education with patients.

• Consider how to identify and best meet spiritual needs of residents in care homes:

o Newcastle - Clergy from the acute trust support care homes

o Wakefield – Chaplain visits the care homes and removes collar

o Sutton – seeking to include a persons spiritual needs in advance care planning.

• If care home staff or nurses feel that a family is struggling, speaking with a GP can sometimes help.

• Nurses and GPs should be open and visible as a profession – being accessible and flexible to fit with families’ needs – this may sometimes involve out of hours.

• Inviting families into the home to talk about advance care planning and disease planning in general with key professionals – e.g. through ‘families meetings’, before their loved one enters the final stages of end of life, can help build understanding and preparedness without it being too difficult and personalised. Sutton vanguard also has a ‘space to have a chat’ system for one-to-one conversations.

• Discuss your service plans with advocate groups e.g. Age UK – for example they can provide information on which advance care plans residents like and find easy to understand. Involve them in strategy meetings as your project evolves.

• Nottingham City’s ‘Worrycatcher’ scheme (delivered by Age UK) provides skilled people for care home residents to speak to with their concerns or feelings – people who are independent of the care provider or health staff in homes. This can allow for a candid discussion and indirect affect how services are improved.

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Challenges and solutions

Challenge Solutions

• Stigma attached and fear • Cannot underestimate how difficult the subject is! You can demystify EOLC through teaching, make people aware of indicators, what’s going to happen, and use training to let people know what to expect and how care home staff can respond.

• Signpost both care provider staff and families and carers to information available online and create materials to increase awareness of what to expect (see Sutton and Newcastle examples)

• Support for care homes when there are deaths – to ensure there is someone to talk to – and support for paid carers and other care home staff after a death – they will be feeling the loss as well.

• Build in time for reflection as an MDT after a death - what went well, what could be done differently and better, what lessons are there to be shared.

• Sharing information on PPOD and care preferences

• Ambulance Service need to be key partners and fully aware of plan - either electronic or strong need to both record and plan - but ensure care home staff are aware and bring to attention and share with LAS when they respond

• Data • Work with your local acute trust and ambulance trust from the beginning of your programme / initiative to ensure a joint approach to sharing care plans and recording data.

• Take a look at the PHE Fingertips website – end of life care profile

• Support for end of life Care training and development

• Consider how you can get support from your Health Education England regional / locality team, local Community Education Providers Network (CEPN) and also from Skills for Care’s regional support. You can also access their resources online.

• Investigate how to effectively provide access to elearning for care homes, domiciliary carers and hospice staff.

• Making the case for improved end of life care and evidencing savings

• Business case - most people don’t want to die in hospital – by investing to support preferred place of death (PPOD), your system can both improve quality of life and contribute to reducing NEL admissions and ambulance callouts - meaning a better use of resource overall.

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https://hee.nhs.uk/



Materials to support implementation

Vanguard schemes Personalised care and support planning • Summary of No One Dies Alone scheme – Newcastle Gateshead

• Gold Line – Out of hours end of life call line for care home - Airedale and partners

• The how, why and what of telemedicine in care homes – learning from a Care Homes Vanguard

• Health Foundation case study (Gold Line)

• Wakefield case study – BB’s advance care planning

• East Lancashire CCG - EoLC Quality Framework Care homes

• Jan 2016 - Dec 2016 Place of death - Rolling 12 Months Report - East Lancashire

• Core information on personalised care and support planning – Coalition for collaborative care

• Information for commissioners

• Practical delivery guidance

• Personalised Care Planning templates and guidance, including templates for advance care plans, emergency care and treatment plans, NHS England

• Macmillan’s Holistic Needs Assessment template

Training materials Job Descriptions

• Identifying Patients in the Last Year of Life in Care Homes (Sue Ryder) - Presentation

• Identifying Patients in the Last Year of Life in Care Homes (Sue Ryder) -Teaching Plan

• Gold Standards Care Plan training booklet

• Prognostic Indicator Guidance October 2011

• React to Red - Pressure Ulcer Prevention Competency Assessment for SSKIN

• Palliative Care Educator (Care Homes) – JD - – East and North Herts

• Palliative Care Educator (Care Homes) - Person Specification – East and North Herts

Contents and

introduction


Benefits and

impacts


tips

Measuring success


you

To do list and

thanks

Before you start



Things to consider

Challenges and

solutions












https://futurenhs.kahootz.com/gf2.ti/f/725698/22119237.1/PDF/-/Airedale_and_Partners_Telemedicine_FINAL.pdf





https://futurenhs.kahootz.com/gf2.ti/f/725698/24415397.1/DOCX/-/Wakefield_Advanced_Care_Planning_CCG_Oct_16.docx








https://futurenhs.kahootz.com/gf2.ti/f/725698/27334437.1/XLSM/-/Jan_2016__Dec_2016_Place_of_death__Rolling_12_Months_Report__East_Lancs.xlsm










https://www.england.nhs.uk/wp-content/uploads/2016/04/core-info-care-support-planning-1.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/04/info-commissioners-care-support-planning.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/04/practcl-del-care-support-planning.pdf

http://www.nhs.uk/Conditions/social-care-and-support-guide/Pages/care-plans.aspx

http://www.macmillan.org.uk/aboutus/healthandsocialcareprofessionals/newsandupdates/macvoice/macvoicewinter2012/holisticneedsassessmentandcareplanning.aspx




































Material to support implementation

East and North Hertfordshire - ABC End of Life Care Education Programme 2015

Sutton’s end of life care approach - Sutton Supportive Care Home Team

A complete training toolkit for end of life care, in particular good care when a person is dying:

• 2a ABC General Information with Application Form for Home or Agency Learner Oct 2016

• 3 ABC Care Home Readiness Aug 2016

• 4 ABC Education Agreement July 2014

• 5 ABC Impact Assessment March 2015

• 7 ABC End of Life Care Learner One Page Confidence Questionnaire March 2015

• 8 ABC Learners Evaluation Oct 2016

• 13 - ABC Photo Consent Form Nov 16

• 14 - ABC Checklist and Audit Tool - Nov 2016

• ABC 2 Day Registration Sheet – Master

• ABC Certificate - Completion of 7 modules

• Sutton Supportive Care Home EOLC model

• Sutton EoLC poster

• Sutton KPIs for EoLC

National tools and resources • Case studies and resources available on the ‘Knowledge Hub’ for

palliative and end of life care.

• Coordinate my care, Coordinate My Care (CMC)

• Information and links for professionals who support people and their families at the end of life, SCIE

• Six Steps to Success Programme, North West Coast Strategic Clinical Networks

• The Good Death Pilot project, Housing for Health

• Toolkit for general practice in supporting older people living with frailty, NHS England

• Public Health England (PHE) Fingertips website – End of Life care profile , iinformation on Place of death, Underlying cause of death, Mortality and Deaths

Contents and

introduction


Benefits and

impacts


tips

Measuring success


you

To do list and

thanks

Before you start



Things to consider

Challenges and

solutions


































http://endoflifecareambitions.org.uk/

http://coordinatemycare.co.uk/

http://www.scie.org.uk/adults/endoflifecare/

http://www.scie.org.uk/adults/endoflifecare/

http://www.nwcscnsenate.nhs.uk/strategic-clinical-network/our-networks/palliative-and-end-life-care/six-steps-sucess-end-life-care/

http://www.housingforhealth.net/good-death-pilot-project-newcastle/

https://www.england.nhs.uk/ourwork/ltc-op-eolc/older-people/frailty/







National materials to support implementation

NHS England resources Care coordination Transforming end of life care in acute hospitals: The route to

success ‘how to’ guide

End of Life and Palliative Care in England: Getting it right

NHS England Specialist Level Palliative Care

Commissioning person centred end of life care – A toolkit for health

NHS England » New quick guides can help us through winter

Case finding and risk stratification

Next Steps for Risk Stratification in the NHS

Core educational framework; case studies of good practice and webinars available on NHS Employers website

Commissioning toolkit for person centred end of life care

EPACCs - electronic systems that improve end of life care, Marie Curie

Lessons learned: Implementing an Electronic Palliative Care Co-ordination System (EPaCCS),

EPaCCS implementation guidance

Summary Care Record for where EPaCCS solution is not in place

Ambitions for Palliative and EoLC • The Ambitions for Palliative and EoLC - a national framework for

local action, End of Life Care Ambitions

Policy and learning Identifying patients for end of life care

• Effective Healthcare for Older People Living in Care Homes, British Geriatrics Society (2016)

• EPaCCS - a case for change, End of Life Care Ambitions

• Government’s response to the choice review including 6 point EoLC commitment

• CQC thematic review of inequalities in EoLC

• RCGP Gold Standards Framework Identification Toolkit

• RCGP prognostic indicator guidance tool can identify whether patients are entering the dying phase of their lives. If this is the case, a discussion should be initiated with patients about their wishes.

• RCGP's End of Life Care microsite

Contents and

introduction


Benefits and

impacts


tips

Measuring success


you

To do list and

thanks

Before you start



Things to consider

Challenges and

solutions

https://www.england.nhs.uk/2016/01/transforming-end-of-life-care/

https://www.england.nhs.uk/2016/01/transforming-end-of-life-care/

https://www.england.nhs.uk/2015/05/laura-tooley/

https://www.england.nhs.uk/wp-content/uploads/2016/04/speclst-palliatv-care-comms-guid.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/04/nhsiq-comms-eolc-tlkit-.pdf





https://www.england.nhs.uk/2015/11/ann-mackay/

https://www.england.nhs.uk/wp-content/uploads/2015/01/2015-01-20-CFRS-v0.14-FINAL.pdf

http://www.skillsforhealth.org.uk/eol-cstf

http://www.nhsemployers.org/case-studies-and-resources/2016/07/end-of-life-care-webinar

http://www.nhsemployers.org/case-studies-and-resources/2016/07/end-of-life-care-webinar


https://www.mariecurie.org.uk/globalassets/media/documents/commissioning-our-services/strategic-partnerships/rcgps/epaccs-electronic-systems-that-help-improve-care.pdf




•http:/endoflifecareambitions.org.uk/wp-content/uploads/2016/09/Lessons-learned-implementing-an-Electronic-Palliative-Care-Co-ordination-System-EPaCCS.pdf



http://www.endoflifecare-intelligence.org.uk/resources/publications/implementation_guidance

https://digital.nhs.uk/summary-care-records/additional-information






http://www.bgs.org.uk/pdfs/2016_bgs_commissioning_guidance.pdf

http://endoflifecareambitions.org.uk/wp-content/uploads/2016/09/Making-the-case-for-change.pdf




https://www.gov.uk/government/publications/choice-in-end-of-life-care-government-response

https://www.gov.uk/government/publications/choice-in-end-of-life-care-government-response

http://www.cqc.org.uk/content/different-ending-our-review-looking-end-life-care-published

http://www.goldstandardsframework.org.uk/cd-content/uploads/files/General Files/Prognostic Indicator Guidance October 2011.pdf

http://www.goldstandardsframework.org.uk/cd-content/uploads/files/General Files/Prognostic Indicator Guidance October 2011.pdf

http://www.rcgp.org.uk/endoflifecare



Implementing high-quality end of life care – to do list

1 Design services based on experiences of patients, families, carers and staff.

2 Develop the partnership (between acute care, community nursing, care homes and social care, working together with hospices and voluntary organisations).

3 Reflect on common goals and shared purpose.

4 Secure buy-in and backing at senior level in each organisation.

4 Embed clinical and care home leadership.

5 Work to introduce and improve arrangements for identifying those approaching the last year of their life, and work with them and their families to develop advance care plans.

6 Ensure there is project management support.

7 Support care home and health staff through high-quality learning and development.

8 Enable high-quality end of life care through effective use of technology and staff.

9 Don’t forget to monitor and evaluate – including getting feedback from residents, families and staff.

Contents and

introduction


Benefits and

impacts


tips

Measuring success


you

To do list and

thanks

Before you start



Things to consider

Challenges and

solutions



Acknowledgements

• Alison Harewood, Lead Nurse, Wakefield Hospice

• Corinne Campion, Team Leader for Supportive Care Home Team, Sutton CCG/Sutton Homes of Care

• Corinna White, NHS Sutton CCG

• Viccie Nelson, Programme Director, Sutton Homes of Care, NHS Sutton CCG

• Jane Moccan, EoL care facilitator, Newcastle Gateshead CCG

• Lesley Bainbridge, Programme Director, Newcastle Gateshead CCG

• Helen Collinge , Transformation, East Lancashire CCG

• NHSE End of Life Care team

Contents and

introduction


Benefits and

impacts


tips

Measuring success


you

To do list and

thanks

Before you start



Things to consider

Challenges and

solutions

ehch element 4.1 high-quality end of life care€¦ · multi-disciplinary team (mdt) support for...

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