hospital to home can it work?
TRANSCRIPT
The Royal Marsden
Hospital to home – can it work? Dr Jayne Wood
Consultant Palliative Medicine
The Royal Marsden and Royal Brompton
Palliative Care Service
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The Royal Marsden
Objectives
• Clinical case • What needs to happen? • What are the barriers? • Hospital2Home, RM • Clinical case revisited
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Joan* 65y
• Jul 14: Stage 4a squamous cell carcinoma cervix with local invasion, pelvic
nodes and vesico-vaginal fistula
• Chemo & RT
• Bilateral hydronephrosis (Oct 10/14) with bilat nephrostomies (right side still in)
• Jul 15: Rectovaginal fistula
• Referred for defunctioning colostomy and formation of ileal conduit
• On admission:
• Deteriorating PS for previous 2 weeks (now PS3-4)
• Reduced appetite and poor oral intake (Alb 26)
• PV faecal incontinence
• Symptomatic: abdominal pain, low mood, poor appetite, vomiting
• Renal impairment: Urea 16 Creatinine 135 (baseline 70)
• Urinary symptoms
• Plan: optimisation of clinical condition before considering surgery
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Case cont.
• Social history: • Warden of sheltered accommodation (also her home) • Lives with husband:
• Recent CVA (mood and memory difficulties; residual right sided weakness)
• Under the care of the community neuro-rehab team • Different GP
• 3 foster children (all in Scotland) • Sister (London) • Known to community nursing team • But:
• No POC • Not known to CPCT • Poor relationship with GP
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Case cont.
• Complications during admission: • Poor nutritional state (TPN) • Bilateral hydronephrosis and AKI (left nephrostomy)
• Bacteraemia following nephrostomy insertion requiring vasopressor support
• Urosepsis & ARDS (requiring transfer to CCU for vasopressor support, Abx & NIV)
• Small bowel obstruction secondary to inflammation around fistula • Pelvic collection (drained) • Recurrent disease at vaginal vault invading pelvic side wall
• Not fit for surgery
• Overall poor prognosis
• PPC & PPD = Home
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Considerations for home
• Symptom control • CSCI • Faecal incontinence
• TPN
• Nephrostomies
• PS 4
• Accommodation
• Needs of husband: • Information • Accommodation after death
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What needs to happen?
• Recognition of dying phase
• Communication with patient … and those closest to them: • Clinical condition • Goals of care • Prognosis • Expectations for dying phase
• Review of current treatments with what can be delivered at home in mind • Anticipation of likely events and ACP
• Application for fast track continuing care funding
• Access visit
• Liaison with community professionals • GP • CPCT +/- affiliated services • Community nurses • Marie Curie sitting service • Social care
• Set a discharge date • Book transport • TTOs
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NHS Continuing Healthcare
• Package of care arranged and funded by NHS
• Not means tested
• Pays for healthcare and associated social care needs, and care home fees
• >18y
• Not dependant on disease, diagnosis, who provides care or where care to be provided
• 4 key indicators identify primary health need:
• Nature (characteristics, type and overall effect if needs)
• Complexity (presentation and level of skill needed to manage care)
• Intensity (extent and severity of needs)
• Unpredictability
• Fast track if urgent POC required due to a rapidly deteriorating condition
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What gets in the way?
• Lack of time: • Failure to recognise dying phase or initiate conversations • Acute deterioration
• Reluctance to: • Communicate • Accept equipment, care and/or support • Manage expectations
• Interventions which cannot be supported in community
• Uncontrolled/complex symptoms
• Inappropriate environment
• Pre-existing poor relationship with community professionals
• Coordination of services (in hospital and out!)
• Availability of health and personal support
• …the little things!
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What makes it go well?
• Patient and those closest to them: • Centrally involved • Appropriate expectations
• Good relationships and an understanding of the patient
• Early: • Involvement of MDT to support discharge • Liaison with community professionals
• Key worker to coordinate • Wandsworth care coordination centre! • Comprehensive communication • Arrival of equipment
• Setting a discharge date
• Perseverance
• Open minded
• …when things happen when they are supposed to!
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The Care Coordination Centre, Wandsworth
– Central point of contact
– Based at Royal Trinity Hospice
– Patients with EoLC needs at home or in a care home
– Joined up and responsive care
– Access to a number of services:
– Health
– Personal care support
– Overnight nursing care
– Advice
– Equipment
0300 3000116
7h00 – 22.30 Mon – Fri
9h00 – 17h00 weekends and PH
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The Care Coordination Centre, Wandsworth
– Team:
– Lead Nurse
– Team of coordinators
– SGH Community Nurse for EoLC
– Marie Curie nursing service team
– Health and personal care assistants (with CC FT funding)
– Referral criteria:
– Prognosis <12 months
– > 18y
– Registered with GP in Wandsworth
– Pt consent (or best interests)
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Hospital2Home (H2H)
– 2007
– Aims:
– Aid transition from acute setting
– Increase achievement of PPC and PPD
– Improve communication with community services
– Improve use of acute beds
– More practically speaking:
– Individualised care planning to develop and share with
relevant community HCP’s
– Formally hand over care to the community professionals
– Enable patient and carer to see that information has been
shared
– Anticipate future problems
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Minimum Dataset 2015
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Background
– William Marsden (1851):
– “A number of beds are provided for the use of
patients who may remain for life…
– RM often perceived to “hold on” to it’s patients
– H2H:
– Palliative care intervention
– Modelled on a successful research project in
Australia (Abernethy, 2006)
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The team
– 2.6 WTE Band 7 CNSs
– Both sites
– Referral criteria:
– Age > 18yrs
– No further active anti-cancer treatment
– Pt aware of the decision
– Registered with a GP and agrees to involvement of the primary and specialist palliative care teams
– Prognosis (days) – months
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Case conferences
– Telephone
– Face-to-face if:
– No community support or complex relationships
with community HCP’s
– Specific symptom control issues eg bleeding,
repeated bowel obstruction
– Community palliative care teams unable to take
on eg brain tumour patients
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Advance Care Planning
– How they would like to be addressed
– Symptom control and anticipated problems e.g. reaccumulation
of ascites, blood transfusions
– PPC/PPD
– DNACPR
– Clarification of which HCP’s will be involved and their contact
numbers (nb OOH)
– Financial issues
– Social Issues including care packages/safety
– OT assessment
– Psychological/Spiritual needs
– Who to contact if re referral to RM necessary
The Royal Marsden
Data: Jan 1st 2015 - 21st Oct 2015
– Total number of F2F case conferences: 27
– 13/14 deaths had PPD documented
– 92.3% achieved PPD
– Total no of telephone case conferences: 176
– 72/84 deaths had PPD documented
– 81.9% achieved PPD
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Steps involved in getting Joan* home!
• Symptom control • CSCI community nursing team • SBO & faecal incontinence (octreotide) adjustment of oral intake;
reduced when in bed; NGT for drainage only
• TPN discontinued and oral intake optimised
• Nephrostomies
• PS 4 Care coordination centre in Wandsworth ordered equipment (bed, air mattress, bed leavers, overbed table & sliding sheets) and volunteers from hospice assisted with removing furniture for equipment
• Accommodation access visit with community case manager
• Needs of husband • Professionals meeting with community case manager • Information shared with support of sister • Housing association to arrange transfer to sheltered accommodation
after death
• Fast track continuing care application successful
• CPCT referral
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Why did it work?
• Patient: • Openly discussed preferences for EoLC • Requested discontinuation of TPN • Agreed to discussion with family • Symptom controlled • Accepted limitations at home
• Professionals: • Early commencement of discharge planning:
• 11th Aug: OT/PT assessment in CCU
• 12th Aug: complex case manager attended hospital for prof meeting
• 13th Aug: access visit
• 14th Aug: CC funding approved
• 17th Aug: 24 hour care approved
• 19th Aug: discharged home
• Joint community/hospital meeting • Access visit • Wandsworth care coordination centre
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COMMUNICATION!
COORDINATION!
FLEXIBILITY!
The Royal Marsden
Objectives
• Clinical case • What needs to happen? • What are the barriers? • Hospital2Home, RM • Clinical case revisited
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