Care Homes

A care home 'is' someone's home, one day it could be yours too …

A care home 'is' someone's home, one day it could be yours too …

Living well and dying well

Objectives of the presentation

• Set the context for End of Life Care • Identify the End of Life Care policy drivers • Examples of best practice care in care homes• Demonstrate what people say they want• Effective engagement with

commissioners/providers • The Six Steps Programme • Video • Key messages

Definition of End of Life Care

End of life care is simply acknowledged

to be the provision of supportive and

palliative care in response to the assessed

needs of patient and family during the last

phase of life.

National Council for Palliative Care(2006)

What do you think constitutes good end of life care?

GROUP WORK

What people say is important to them at the end of their life

• Communication -Being listened to• Respect• Dignity, respect and compassion• Seeing me as a person not a disease • My wishes respected wherever possible- including place

of care

• Remember my family and support network • My spiritual and religious needs met• Being symptom free

500,000 people die each year, there is a major discrepancy between people’s preferences for where they should die and their actual place of death

•Most when asked, identify that they would probably like to die at home

•Only around 18% do so with a further 17% in care homes

•Acute hospitals accounting for 58% of all deaths

•Around 4% in hospices

Where do people die?

End of Life Care Strategy(DH 2008)

1.The challenges of end of life care

2.Death, dying and society

3.The end of life care pathway

4.Care in different settings

5.Support for carers and families

6.Workforce

7.Measurement and research

An ageing population

England : The proportion of the total population aged 65 and over

Source :Office of National Statistics http://www.statistics.gov.uk/downloads/theme_population/NPP-2006/NPP06_NSOnline.pdf

0

5

10

15

20

25

2006 2010 2020 2030

Proportion of all ages population

65-74

75-84

85+

The demographic challenge add Graphs Gnomes and Higgingon Rising expectations – leading to complaints please add references to

NCEPOD and HCC complaints Political and public demands for best use of resources

The drivers for change

Actual and projected deaths England Wales

Source : Gomes and Higginson; Where people die (1974–2030): past trends, futureprojections and implications for care., Palliative Medicine 2008; 22: 33–41

QIPP and the End of Life Care Strategy

• Taken as a whole, the strategy fits all the QIPP criteria, from quality to prevention: and implementation carries on for all the work people have established

• The EoLC QIPP workstream concentrates on the early part of the pathway: identifying people as they approach the end of life and then planning their care: if we don’t get this right the rest of the strategy has no anchor.

• QIPP will help us to accelerate this strand of the work• In the meantime, we need to ensure that services are in

place to provide the care for patients and their relatives/carers, in the place of their choice.

Key Levers Key Levers for improved Carefor improved Care

Patient Patient achieving their achieving their

wishes and wishes and preferences at preferences at end of life of end of life of where they where they want to die want to die

Reduction in Reduction in inappropriate inappropriate

hospital hospital admissions admissions

Equity and Equity and access to end access to end

of life care of life care

What tools are available to support?

• Gold Standards Framework

• Preferred Priorities of Care

• Liverpool Care Pathway for the dying Patient

• Blended Education; including e-learning, Macmillan foundations training, Routes to Success and Six Step programme

Support for Implementation

Death, dying and society

National Coalition – Dying Matters

Over 14,000 members

First Awareness Week March 2010-

Second planned w/c16 May 2011

Materials available on website

www.dyingmatters.org

www.dyingmatters.org

Examples of best practice:Education & Training• Implementing a 6 month support and training

programme in care homes in Avon, Gloucestershire and Wiltshire NHS South West

• Involved 12 care homes • Joint training programmes can help to combat

the sense of isolation among many care home staff

• A combination of education and mentoring can have a big impact

Example of best practice:Liaison and Support to care homes

A scheme to support and advise care home staff in Warrington has cut hospital admissions and given residents greater choice about where they die.

Between April 2009 and March 2010, the number of A&E attendances from care homes in Warrington has dropped by 250, emergency admissions have fallen by 288 and a total of 8,836 hospital bed days have been saved.

Example of best practice:LCP in care homes• Northamptonshire NHS Provider Services have

developed a step approach to LCP implementation in care homes

• The process involves training beforehand, ongoing support once the LCP is being used and participation in the LCP Reflective Data Cycle

• Seventy per cent of those who died in care homes registered with the project had their care guided by the LCP.

Examples of best practice: Enabling individuals to remain in their home• Improved liaison with primary care trust services is

enabling patients with Huntington’s disease in Strood, Kent to remain in care homes (personal care) until they die

• Regular meetings held with dieticians, speech and language therapists, Palliative care critical nurse specialists.

• Regular patient reviews with GPs and palliative medical consultants

“ It should not be down to ’luck’ and where we live in the country as to how we die, we all know death happens and we should be more prepared, human and caring”

Comment posted on the Patient Opinion

website www.patientopinion.org.uk

How do we ensure there is effective engagement between commissioners, care home providers?

GROUP WORK

How will the resident & family/commissioner/care home know it has worked

• Residents receive their wishes and preferences at end of life

• Family feel supported• Use of Liverpool Care pathway/Six Steps to Success

programme demonstrates quality care given• Staff are trained and competent to deliver the care • Fewer complaints• Reduction in inappropriate hospital admissions• Equity and equal access to quality end of life care to all

CQC

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

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

for InspectorsHow 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• Systems in place to access relevant members of PHCT• 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)

Discussions as end of life approaches

Discussions as end of life approaches

Assessment, care planning and review

Assessment, care planning and review

Delivery of high

quality services

Delivery of high

quality services

Care in the last days of lifeCare in the last days of life

• Strategic coordination

• Coordination of individual patient care

• Rapid response services

• Identification of the dying phase

• Review of needs and preferences for place of death

• Support for both patient and carer

• Recognition of wishes regarding resuscitation and organ donation

• Recognition that end of life care does not stop at the point of death.

• Timely verification and certification of death or referral to coroner

• Care and support of carer and family, including emotional and practical bereavement support

Care after deathCare after deathCoordination of careCoordination of care

• High quality care provision in all settings

• Hospitals, community, care homes, hospices, community hospitals, prisons, secure hospitals and hostels

• Ambulance services

• Agreed care plan and regular review of needs and preferences

• Assessing needs of carers

Support for carers and families

Information for patients and carers

Spiritual care services

The End of Life Care Pathway

Step 1 Step 2 Step 3 Step 6Step 5Step 4

• Open, honest communication

• Identifying triggers for discussion

Why?• Fits with the End of Life Care Strategy identifying the need

for a cultural shift in attitude & behaviour across the health & social care workforce towards end of life care

• 10% reduction in inappropriate hospital deaths ( North West Healthier Horizons 2008)

• Provide stronger partnerships between the NHS and the independent care sector

• Address the key components of End of Life Care education to support care homes in providing end of life care i.e. Advance Care Planning, communication skills & Liverpool Care Pathway

• Improving equity of quality end of life care for all residents in a care home.

• Delivery of quality end of life care in care homes requires an effective balance of external support and internal resources.

QIPP

Quality •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

The Future ‘more work is needed to enable integration of

nursing homes into the wider systems of end of life care and to enable collaboration across organizational, institutional and funding boundaries so that patients receive a better quality of end of life care regardless of the care setting in which they are located’.

Jane E Seymour, Arun Kumar and Katherine Froggatt (2009)

My Home Life Video

Supporting good end of life care video

Reference:

www.myhomelife.co.uk

“You matter because you are you. You matter to the last moment of your life and we will do all we can, not only tohelp you die peacefully, but to liveuntil you die.”Dame Cicely Saunders

References

• www.endoflifecareforadults.nhs.uk

• www.dyingmatters.org.uk

• www.goldstandardsframework.nhs.uk

• www.patientopinion.org.uk

• www.mcpcil.org.uk

Contact us:

Website www.endoflifecareforadults.nhs.u

Email information@eolc.nhs.uk

Telephone 0116 222 5103

National End of Life Care Intelligence Network

www.endoflifecare-intelligence.org.uk