end of life care annamarie challinor macmillan end of life programme lead east cheshire trust
TRANSCRIPT
End of Life Care
Annamarie Challinor
Macmillan End of Life Programme Lead East Cheshire Trust
Objectives of the workshop;• Raise the profile of end of life care across ECT• Deliver an overview on the end of life care service
model • Share some of the outcomes from the model • Describe some of the current projects underway• Outline potential cost savings
Putting End of Life Care into context.....
Everybody’s business.....• Average 4,400 deaths per year • Fastest growing ageing population in N/West• 80% of the population increase aged 65 and over.• Above UK average life expectancy • 35,000 people not in good health with long term illness• Heart disease and cancer biggest cause mortality
End of Life Care inAcute Hospitals;
• 70% would prefer to die at home only 18% do so• 40% people dying in hospital have no medical
need to be there• Current trends suggest 20% increase in
institutional deaths by 2030• 54% Acute hospital complaints relate to end of
life care • A proportion of patients dying in hospital receive
very poor care without optimal symptom control
Facilitating best practice in End of Life Care conventional approaches
Prior to 2009 this was led by a number of single and temporary post-holder’s who were;
•Externally funded•Promoting use of one of the end of life tools only •Employed to work within either the acute trust only or Community only
Drawbacks experienced:•Heavy reliance on one individual
• Lack of continuity across care settings (which our patients frequently traverse) • Over-emphasis on healthcare
• Lack of sustainability and ownership from within the organisation
• Restrictive & unrealistic facilitator project timeframes
What did this lead to?• Isolated areas of best practice
• Disjointed and uncoordinated approach
• Difficulties with recruitment & retention of facilitator’s
• Failure to address a whole systems approach
• No change in the culture of care- tendency to blame systems of others
• Patchy/ lack of use & application of end of life care tools
• Disempowered staff (we have been here before...)
Some ultimate consequences for the patient & their family:
• Failure to meet Preferred Priorities for Care (PPC)• Inappropriate admission to hospital (especially from care homes)• Poor coordination and planning of care• Late recognition of end of life patients• Ineffective symptom management• Inappropriate treatment’s and interventions• Increase in complaints• Carer burden • Impact upon the bereavement process
Strengths of the old approach;East• Location of the facilitator more visual and
accessible therefore more responsive• Dedicated and protected facilitator time• Ability to work across organisational boundaries• Wearing a ‘NHS/PCT hat’ helps
Central• Strength in numbers• Underpinned by a strong educational ethos• Strong affiliations with supporting networks • Looked upon as the ‘experts’
However;• Both approaches operated separately and lacked integration and cohesiveness.
•Loss of the single post-holder resulted in lost momentum, motivation and discontinuity in one sector
•The education team/organisational approach lacked dedicated time and continued funding
• There was a total reliance upon external funding from the cancer network to continue facilitation
Therefore;We needed to promote equity across the locality by sharing best practice across organisational boundaries so that wherever the patient was being cared for and whatever their condition, their end of life care was consistently good
We needed to make best use of existing resources & funding.
• Model Diagram to provide visual clarity • Mindful of locality based issues (East & Central)• Supportive of a coordinated & streamlined approach across
the PCT• Enable the sharing of best practice• Promote local ownership/ sustainability• Responsive to traditional boundaries/ barriers• Inclusive of all care settings/ disciplines • Led by expert clinicians from cancer & non cancer specialities• Underpinned by bespoke education• Cost effective and attractive to investment• A foundation Model with flexibility to change and expansion
Developing the model;
Central & Eastern Cheshire End of Life Service Model
Group B Workforce
East Cheshire HospiceMacmillan TeamSpecialist Teams
Cheshire Hospices Education
St Luke’s HospiceMacmillan TeamSpecialist Teams
Central & Eastern Cheshire End of Life Service Model
Group B Workforce
East Cheshire HospiceMacmillan TeamSpecialist Teams
Cheshire Hospices Education
St Luke’s HospiceMacmillan TeamSpecialist Teams
LINKS TO SOCIAL CARE
Admin Support
The End of Life Service Model A local vehicle to deliver:
• Both a bottom up and top down approach to priorities• A service which is visionary, complimentary and considerate of wider end of life initiatives (local,
strategic and national) therefore reducing the likelihood of ‘reinventing the wheel’ or introducing costly & ineffective interventions
• A service informed by an abundance of best practice• A service which is locally owned and developed• Audit & data collection• Clinical expertise and advice in end of life care• Bespoke education across organisations• Project management• A whole systems approach to service transformation
Some outcomes since 2010 for
East Cheshire Trust Acute & Community
Rapid Discharge Pathway
Preferred Place of Care (Home)
• Pathway to facilitate Rapid Discharge for those patients who are in the last days of life and who’s preferred place of care is home (including a care home)•Collaborative approach to development/ implementation & evaluation of the pathway• Involved community, acute, voluntary, NWAS & coroner
3 patient’s since April 2011 discharged on the pathway- feedback collated as part of ongoing audit from the receiving community team and from patient relatives
Use of the End of Life Pathway• Greater uptake of the End of Life Care
Pathway (10.1% all deaths in 2008 to 23.2% +)
• Increased length of time on the pathway• Increase in standards of documented
care at end of life• Increase in proactive prescribing
for potential end of life symptoms
Community data collection tool • Primary & community led • Captures patient end of life journey • Used as a reflective practice tool• 43/51 practices engaged/ participating• Data includes achievement of Preferred Place
of Care (and challenges to achieving this), Out of Hours communication, Advance Care Planning, use of the end of life care tools including rationale for non use
• 486 deaths captured 2010-2011• Qualitative data to tell ‘real patient stories’
Background of e-paige
End of Life Education & Training
Contribute to e-paige
Evaluate this resource
Further help and advice
electronic Prognostic Assessment & Indicator Guide for End of life (e-Paige)
Bereavement
One year +
First Days after Death Last Days
of LifeIncreasing decline
Advancing disease
Up to 1 year
Death
Increasing Decline (less than 6 months prognosis)
12
4 53
The following aspects of care should be considered for the patient with increasing decline in their illness;
•Recognition by both the patient and the multi-professional team of the signs of increasing decline•Open and honest communication with both the patient and, where indicated, their significant others• Conduct a holistic assessment to ensure that the care and treatment delivered is based on need• Advance Care Planning discussions and documentation should include the management of both future crisis and sudden deterioration including the avoidance of inappropriate admissions to hospital• Optimisation of treatment will need to be considerate of disease type and the presenting symptoms• Coordination of care should include Specialist Teams, Primary & Community Care, and the wider Multi-Professional Team•Consider whether carer support may be required when the patient is discharged home• The patient may be entitled to various means of financial support• Provide access to both national and local information which is tailor-made to the individual’s needs
•
Bereavement Resource
• Combined community and acute booklet• Project collaborated with voluntary care, care
homes and Leighton Hospital • Cheshire wide resource allowing a consistent
quality of information to be delivered to the bereaved regardless of care setting
• Inclusive of tear out feedback slip to measure qualitative data i.e. Were you given opportunity to speak with staff looking after your relative/friend
Communication Skills Training Strategy
• Cost effective model making best use of available funds and skilled workforce
• Central & Eastern Cheshire Wide• Self sustaining in the longer term• Competency based with associated learning outcomes• Facilitating a safe environment for attendees to
explore communication challenges pertinent to their role
• Focus on shift in culture as opposed to ‘tick box’ exercise
Award; Multi-disciplinary Team of
the Year 2011(International Journal of Palliative
Nursing)
Impact on patient care?• More timely and appropriate care
• Better prognostication• Evidence based pathways• Fewer patients slipping through the net• Proactive as opposed to reactive care• More effective symptom management
• Fewer inequities based on care setting or disease type•Wider disease groups benefitting • Raising the profile therefore quality of end of life care in all care settings
• More skilled and competent workforce• More patients having their end of life preferences discussed• Better communication between patient and professional, and within and across organisations• Increased availability of patient and carer information
• Better coordination and communication between and within services
• Streamlined end of life care services• Increased possibility of dying in Preferred Place of Care
Cost saving?
•Bed days- Rapid discharge, reducing inappropriate admissions•Pathways- avoiding inappropriate & costly treatments and tests • Facilitator funding- more effective use of funding allowing consistency and continuity of projects• Reduction of waste in resources- in terms of staff time and from ‘re-inventing the wheel’ – doing things right 1st time• Potential cost generating - CQUIN’s/ KPI • Cost effective model – innovative & attractive to external funding
Alignment with Trust Objectives;Continuously improve quality, safety and the patient
experience
Supporting and developing staff to enable them to achieve their best
Achieving financial sustainability
Working with our partners to provide an integrated health service for our local population
Encouraging staff to be innovative when delivering and planning services
