Facilitator - Alison Doyle

The North West End of Life Care Programme for Care Homes

Induction

• Introductions• Ground rules• End of life care drivers• The Route to Success in Care Homes• Overview of Six Steps Programme• Portfolios• Change management• Audit Cycle• Group work• The way forward

Objectives

Identify National, Regional and Local end of life care drivers

Understand the programme Commence the audit process Have an understanding of your role and

responsibilities Commence an End of Life Care Policy

End of Life Care

‘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 patients and family to be identified and met throughout the last phase of life and into bereavement. It includes the management of pain and other symptoms and provision of psychological, social, spiritual and practical support’

(National Council for Palliative Care)

Palliative Care - WHO 2002

• Provides relief from pain and other distressing symptoms

• Affirms life and regards dying as a normal process• Intends neither to hasten or postpone death• Integrates the psychological and spiritual aspects of

care• Offers support system to help patients live as actively

as possible until death• Offers support system to help families cope

Palliative Care

• Team approach to address needs• Will enhance quality of life, may positively

influence the course of illness• Applicable early in the course of the illness,

with other therapies intended to prolong life, e.g., chemo, radiotherapy, investigations to better understand and manage distessing symptoms.

End of Life Care Strategy 2008

• 1/2 million people die each year• 58% deaths - hospital• 18% deaths - home• 17% deaths - care home• 4% deaths - hospice

Most people would prefer NOT to die in hospital

End of Life Care Strategy 2008• Vast majority of deaths = over 18yrs (99%)

• Most deaths occur in the over 65’s

• By 2030 - over 65yrs, 86% of deaths over 85 yrs, 44% of deaths

• Over 85 yrs = more likely to be in care home (currently)

• 1/5 NHS spending is on EOLC

• 40% who die in hospital don’t have medical conditions that medics can fight (Demos UK, 2010)

End of Life Care Strategy 2008

AIM:

• Better access to high quality care at end of life

• Available wherever the person may be

• Achieved through 10 objectives

End of Life Care Strategy 2008

Objectives:• Increase public awareness• Ensure dignity and respect• Optimum quality of life (symptoms)• Access to holistic care services• Needs identified, documented, acted on,

reviewed• Coordinated services

End of Life Care Strategy 2008

• High quality care in last days of life and after death, in all care settings

• Carers supported• Health care professionals supported with

training and education• Services - good value for money

NW EOLC Clinical Pathway Group

Key recommendations:

• Robust integrated commissioning framework with strategic leadership in every PCT• Quality standards and measures• Raising public awareness• Build on success of EOLC tools• Advance Care Planning - all sectors

NW End of Life Care Clinical Pathway Group

Headline aim

To reduce hospital deaths by 2012 by 10%

NHS Sefton EOLC Strategy

• Recognises palliative care - availability to non cancer patients

• More investment in services from NHS• Implement NICE Guidance on Supportive & Palliative

Care for Adults with Cancer 2004• Implement recommendations of NHS North West

EOLC Clinical Pathway Group (Incl’ reducing hospital deaths by 10%)

• Increase use of nationally recognised EOLC tools (LCP 100% uptake)

CQC

CQC (2010) End of Life Care Prompts Care Homes: Guidance for Inspectors

How should a care home that provides end of life care support the person?

CQC questions to consider…• Do staff have knowledge & skills to identify EoLC needs. A relevant care assessment is in

place• Needs assessment reviewing, pain, tissue viability, nutritional needs etc• Are residents and loved ones included in the decision making process.• Are residents given the opportunity to discuss PPC• Is there a policy & training for staff with clear records if a DNAR is recorded• Do the staff use a pain chart• Do documents used support end of life planning e.g. LCP• The least possible disruption to the individual and their family and those close to them

(see CQC Guidance for inspectors)

End of Life Care Quality Markers and Measures

Care homes - • Based on structures and processes of care likely to

achieve good outcomes• Consistent with holistic approach to care• Designed as supportive guide• Do not always require new ways of working/thinking

12 quality markers (generic) Quality markers dementia and end of life care (Living well with Dementia (DH, 2009)

End of Life Care Quality MarkersFor Care Homes

• Action Plan for EOL• Mechanisms to discuss, record wishes (ACP) • Residents needs assessed and reviewed• Nominate a key worker for each resident at EOL• Residents who are dying are entered onto a care pathway• Families and Carers are involved in decisions at EOL to the extent they

wish• Other Residents are supported following a death• Quality of EOL care is audited and reviewed• Process to identify training needs of all workers, common requirements –

communication skills, assessment and care planning, ACP and symptom management

• Training needs addressed for those staff initiating ACP• Aware and encourage attendance to EOL care training• Review all transfers in and out of the care home at EOL

QIPP

‘One of the most significant NHS policies all organisations connected to the NHS will have to take on board’

• Effects every department and individual• Identification of efficiency savings• Reinvestment to deliver quality

improvements

QIPP

Example• Fractured neck of femur - redesign of service,

improved quality by improving m.d. and cross agency teamwork =

reduced mortality, reduced time to theatreearlier mobilisation, reduced length of stayreduced readmissions.

QIPPQuality •Improve the resident and family experience of end of

life care in a care home setting•Enhance care delivery within the care home at end of life•A skilled workforce

Innovation •A low cost Network EOL programme providing a consistent approach across PCT’s with a wide access to all care homes•Can support care homes who currently have high recorded admissions to the acute sector for end of life care•Develop a care home representative to take responsibility for the future development of end of life care provision in their care home

Productivity •Enhanced end of life care •Enhanced MDT working •Deliver choice at end of life•Wider awareness and implementation of End of life care •Development of PCT End of Life Care home representative Groups•Address equity

Prevention •Reduction in hospital admissions at end of life from Care homes•Reduction of isolated working

Six Steps

• Step 1 Discussions as the end of life approaches• Step 2 Assessment, care planning and review• Step 3 Co-ordination of care • Step 4 Delivery of high quality care in care homes• Step 5 Care in the last days of life• Step 6 Care after death

Managing Change

Why change?

• Response to government initiatives• Response to audit, reflective practice,

complaints, critical incidents• Diversity of patient demand

Barriers to Change

• Awareness, knowledge• Motivation• Acceptance and belief• Skills• Practicalities

Identify barriers to change

• Talk to key people• Observe clinical practice• Use of questionnaires• Focus groups• Brain storming

Change Models

• The 7 S Model• 5 Whys• PESTELI• Force Field Analysis

Ready for Change?

• What do your colleagues think?• Conflict with other important initiatives?• Identified key frameworks?• Consider how change has been successfully

implemented in the past, what works best?• Leading your project - SWOT analysis• Action plan

Emotional Cycle of Change

• Panic• Despair• Blind optimism• Cautious optimism• Denial• Confidence in the future• Success

Attitudes to Change

• Innovators (venturesome)• Early adopters (respectable)• Early majority (deliberate)• Late majority (skeptical)• Laggards (traditional)

Managing Change

“Involvement is the key to implementing change and increasing commitment….. It acts as a catalyst in the change process”

(Covey, 1992)

Resources

• www.nhsleadershipqualities.nhs.uk (LQF)

• www.nice.org.uk (How to change practice)

• www.sdo.nihr.ac.uk (Managing change in the NHS)

What is Audit?

Simply put….

“A tool to aid you in improving patient care by looking at current practices and making changes where necessary”

Difference between Audit and Research

Research

Quest for new knowledge

Seeks to define best practice

‘What is the right way?’

Audit

Evaluates conformity with knowledge that’s has been tested and proven to be acceptable to the majority

Seeks to evaluate if best practice is being delivered

‘Doing it right’

Simple RulesClinical Audit Measures existing practice against

evidence-based clinical standards

Research Generate new knowledge where there is no or limited evidence available and which has the potential to be transferable.

Service evaluation

Service/practice evaluation evaluates the effectiveness or efficiency of an existing/new service/practice that is evidence based with the intention of generating information to inform local decision making. E.g. baseline audit, benchmarking, clinical effectiveness study.

Audit Cycle

Why Audit?

Consistency of care and treatment Improve access, equity of healthcare Improve quality and effectiveness of care Improve satisfaction Improve awareness of guidelines and standards Identification of training needs Quality assurance Risk management, reduction in complaints/litigation

Death and Dying

• Taboo• Coped well in past• How would most wish to die?• How will most die if we don’t make changes?• People need to talk about dying, not euphemisms• ACP should be the standard

What is a ‘good death’?

• Being treated as an individual, dignity and respect

• Without pain and/or other symptoms• In familiar surroundings• In company of close family and friends

What makes a good death?

Exercise

1. The Resident2. The Family3. The Carer

Expectations of an End of Life Care Home Representative

• Attend all of the Six Steps to Success workshops• Take lead role, support and develop others in EOLC• Keep knowledge and skills up to date• Build resource files within the care home• Produce a portfolio to evidence the implementation of the

programme that could be shared with regulatory bodies(CQC), commissioners, social services

• Ensure EOLC tools promoted and used in care home• To be a link with the local End of Life Care Facilitator• Initiate change management within the home

End of Life Care Policy

Summary

• End of Life Care Drivers• Six Steps to Success programme• Change management• Audit• Your role and responsibilities• Portfolio of evidence• End of Life Care Policy, philosophy• To do

Any Questions?