Gold Standards Framework in Care Homes

1
Gold Standards Framework in Care Homes

• Nikki Sawkins GSFCH Lead Nurse

2
Plan of session

• Context of GSF in End of Life Care
• What are the challenges?
• What is GSF in Care Homes ?
• Evaluation and Experiences of others
• Developments and Plans
• Are you interested? Next Steps

3
End of Life care

• Do any of your
• patients
• ever die?
• Then you
• need to think about
• end of life care.

4
Clarification of Terms

• End of Life care
• Pts living with the condition they may die from-
  weeks/months/ years
• pts with advanced disease
• 3 types of pt (cancer, organ failure ,frail
  elderly /dementia pts )
• Ante-mortal care like ante-natal or early life
  care
• Supportive Care
• Helping the patient and family cope better with
  their illness
• not disease or time specific, less end stage
• Preferred by some specialists- everyone needs
  supportive care
• Palliative care
• holistic care (physical psychological, social,
  spiritual )
• specialist and generalist palliative care
• Some regard as overlapping or following curative
  treatment
• Terminal care
• Diagnosing dying-care in last hours and days of
  life

End of Life Care
Supportive Care
Terminal Care
Death
Palliative Care
5
DEMOGRAPHIC TIME BOMB

• More people are living longer, with serious
  disease and increased symptom burdens
• Almost double life expectancy in 100 years
• Increased complexity in looking after patients
  with advanced disease at the end of their lives

6
Why are we leaving it to luck?
Joanne Lynn

• What will we need when we have to live with a
  fatal disease?
• We need reliability, We need a care system we can
  count on- Doing RIGHT thing at RIGHT time
• To make excellent care routine we must learn to
  do routinely what we already know must be done
• All that it takes is innovation, learning,
  reorganisation and commitment

7
Added Value 2 Caring for people with
non-malignant conditions and the frail elderly
GP has 20 deaths per year
8
Key Factors with end of life care of elderly

• Multiple co-morbidities
• Increasing memory loss/dementia
• Difficulty predicting prognosis
• Difficulty predicting dying phase
• Complex social/ health factors
• Need protection from over intervening - eg DNAR,
  trolley deaths

9
Place of death Higginson I (2003) Priorities for
End of Life Care in England Wales and Scotland
National Council

• Place Home Hospital Hospice
  CareHome
• Preference 56 11 24 4
• Cancer 25 47 17
  12
• All causes 20 56 4
  20

10
Gold Standards Framework

• 3 Programmes of work
• GSF in Primary Care
• GSF in Care Homes
• EOLC developments and support

11
The Gold Standards Framework

• A framework to deliver a
• gold standard of care
• for all people approaching the end of their
  lives
• A systematic approach to optimising the care
  delivered by healthcare professionals

12
A good death for all

• Our aim is that every person should be able to
  live well and die well in the place and in the
  manner of their choosing
• But how?

13
Gold Standards Framework in Community
Palliative Care

• The Aim for Primary Care and Care Home teams
• to develop a practice-based/care home based
  system to improve
• the organisation and quality of care of
  patients/residents in the last year/s of life in
  the community/care home
• So generalist better dovetail skills with
  specialists

14
Head Hands and Heart of Community Palliative
Care
HANDS - process/organisation - systems -
how to do it
HEAD - knowledge - clinical competence - what
to do

• HEART
• -compassion/care
• human dimension-why
• - experience of care

15
The Gold Standard of end of life
care

• The care of ALL dying patients
• is raised to the level of the best.
• (NHS Cancer Plan 2000)

16
GSF 3 Steps then provide

3. Plan
2. Assess
communicate
1. Identify
17
5 Goals of GSF

• Patients are enabled to have a good death
• 1) Symptoms controlled
• 2) Preferred place of care
• 3) Safe secure with fewer crises
• 4) Carers feel supported, involved, empowered,
  and satisfied.
• 5) Staff confidence, teamwork,
• satisfaction, co-working
• with specialists and communication better.

18
7 Key tasks/ standards-The GSF 7 Cs

• C1 Communication
• SC Register and PHCT Meetings, Pt info, PHR,
• Advanced care planning (ACP) eg PPC
  
• C2 Coordinator
• Key Person, assessment tools eg PEPSI COLA
• C3 Control of Symptoms
• Assessment, body chart, SPC ,ACP etc
• C4 Continuity Out of Hours
• Handover form OOH protocol
• C5 Continued Learning
• Learning about conditions on patients seen
• C6 Carer Support
• Practical, emotional, bereavement, National
  Carers Strategy

19
Underlying assumptions of GSF

• Care for people who are dying is important!
• Most want to give best end of life care GSF
  enables and encourages this
• Developed from primary care for primary care
• Developed and adapted for care homes by care
  homes - from the bedside not the
  boardroom
• Raise awareness of dying pts and measures
• Framework not prescriptive -Adapt and adopt-
• Becomes standard practice -this is what we do
• Patient/resident focussed- Proactive- Think of
  future needs
• Encourages creativity and pride in our work
• National momentum-Share learning and ideas with
  others
• If it was you.

20
In hours Proactive Palliative Care-Avoidance of
crisis-eg GSF/GSFCH

• Anticipatory care helps avoid crises
• -improved support for residents, families staff
• reduction in hospital/hospice
• admissions
• (12 reduction in crisis admissions at EOL -
  phase 2)
• achievement of preferred
• place of care/death
• (8 reduction Hospital deaths)
• .and reduce fear

21
GSF Supported Spread Cascade

• National team

GSF Project group
SHA, Ca Network
Co-ordinators
Facilitators
22
GSF Spread UK wide

• Use of GSF
• About 3800 practices over a third of all
  practices in England. Over 80 of PCTs
• Over half practices in Scotland, a third in
  Northern Ireland, beginning in Wales and other
  countries

23
So What do we know?
24
GSF Evaluation Nationally

• Better identification and tracking of patients
• More notingattaining preferred place of death
• Better communication, teamwork and planning
• Fewer crises/admissions
• Better organisation consistency of standards
  eg use protocols, assessment tools, information,
  bereavement care , even under stress
• Better co-working with specialists

25
GSF Evaluation Nationally

• Attitude, approach, awareness qualitative
  factors that underpin the culture of practice,
  hard to measure, but often the most valuable
• Processes and patterns of working practical
  system redesign processes that are more
  structured and formalised
• Outcomes reduces hospital admissions, reduced
  hospital deaths, more advance care planning
  discussions
• GSF Evaluation by the University of Birmingham

26
GSFCH Care Homes

• Planning- 2003/4- GSF adapted for Care Homes
• Phase 1 pilot- -May- Dec 04
• 12 care homes in 6 areas
• Report March 05
• Phase 2 pilot-June 05- Feb 06
• 100 care homes with 35 facilitators-18 /28 SHAs
• Research study Birmingham University funded by
  Macmillan
• Phase 3 Programme -June 06- Feb 07
• About 250 care homes 3 bases Crawley phase 3a
• Continuing evaluation
• Phase 3b Crawley and Phase 4 Programme June 07
  March 08 Open and Commissioned areas.

27
(No Transcript)
28
Gold Standards Framework in Care Homes - GSFCH

• Aims
• To improve quality of end of life care
• To improve collaboration with primary care and
  specialists
• To reduce admissions to hospital in the last
  stages of life

29
Context

• Half a million people live in Care Homes-about 1
  Approx 20 people die in Care Homes
• 86 all deaths in people over 65, 51 in people
  over 80 For every NHS bed, there are 3 Care homes
  beds
• The sector employs about 1.2 million people
• People stay on average 2-2.5 years in Nursing
  Homes
• An average N. Home with about 30 beds might
  expect about 1 death/ month, or about a
  third/quarter turnaround /year

30

• If you are old and in a care home,
  you know you are probably going to die
  quite soon. Most older people dont think that
  dying is a tragedy, though they do think that
  dying with unresolved issues is.
• Prof Ian
  Philp
• National Director
  for Older people
• The Times Sat
  3.6.06

31
End of Life Care- Getting it
right

• Theyll never forgive you
• if you dont
• Theyll never forget you
• if you do

32
Experience of GSFin Care Homes

• Attitudes, awareness and approach
• eg confidence all staff,
  care needs focus, proactive care
• Patterns of working, structure/ processes
• eg communication all
  staff, recording, information sharing
• Outcomes
• eg more advance care plans,
  fewer crises,
• better quality of
  dying, staff feel valued

33
Does using GSF help patients with end of life
care needs in care homes?

• It helps coordination and communication
• It helps confidence of staff
• It helps us focus and measure
• It helps kick start changes
• It helps specific things like needs based coding,
  Advance care plans, anticipatory prescribing,
  communication with GPs etc

• Y E S

34
GSFCH Open Programme Plan Phase 4 -Walsall

• 
  
  
• ADA
  ADA
• 
  
  
• Preparation Introduction
  Consolidation consolidation/embedding
• July 2007
• ..First gear.Second gear..Third
  gear.Fourth gear
• Workshops
• 26 Sept 07 5 Dec 07 27 Feb
  08 7 May 08

35
Four Gears

• Getting going
• Coding, Register
• Meeting,
• Coordinator
• Moving on
• Assessment of symptoms Advanced care Planning
• Out of hours continuity
• Education and reflection

• 3. Gaining Speed
• Education and reflection
• Carers and family support Bereavement (and staff)
  
• 3. Care in Final days
• 4. Cruising
• Sustain
• Embed
• Extend

36
Phase 4 Evaluation

• 1. After Death Analysis Electronic Format
  Register on line
• Background information
• Last 5 patient deaths before and after GSF
  introduction
• What went well, what didnt go so well, what
  could we do better.
• Feed back of information.

37
Online After Death Analysis (ADA) Audit Tool
38
Networking and speed-dating

• Sharing experiences with others key to
  learning,finding solutions to some of the
  challenges, sharing good ideas, handy hints.
• Eurekas Things that have worked for us
• Speed dating- capturing specific topic issues
• Good Practice Guide shared learning and
  experience

39
SO WHAT!
40
Reactive patient journey-MR B in last months of
life-

• Care Home no discussion wishes for end of life
  (only burial/cremation) -no PPOC discussed or
  anticipated
• Problems with symptom control-high anxiety
• Crisis call eg OOH-no plan or drugs available -
  GP sent ambulance
• Admitted to hospital disorientated.
• Dies in hospital ?over intervention/medicalised
• Carer support in grief by care staff
• No reflection/improvements by care home/GP
• ? Inappropriate use of hospital bed

41
GSF Proactive pt journey- Mrs W in last months
of life

• Coded on Register-discussed at Care Home GSF
  meeting
• Focus of care at stage of life
• Regular discussion and planning with care
  home/GP/SPC - proactive care
• Assessment of symptoms -referral to
  SPC-customised care for resident
• Carer involvement in care/decision (residents
  wish)
• Advanced Care Plan completed with resident and
  family - Preferred place of care noted and
  planned.
• Handover form issued ACP wishes anticipatory
  drugs issued in care home
• End of Life pathway/LCP/protocol used
• Pt dies in preferred place- the care home fully
  supported by well trained staff. Bereavement
  support for all .
• Staff reflect-ADA and SEA - audit gaps improve
  care, learn

42
GSF and GSFCH is part of the jigsaw

• GSF/GSFCH is part of the jigsaw to enable
  proactive end of life care for all.

43
GSF and Prognostic Indicator Guidance

• Development of a Prognostic Indicator Guidance
  paper PIG, in consultation with national leads
  and organisations
• More challenging identifying patients with
  non-cancer for SC register
• Evaluation shows that 60 of practices are
  including non cancer patients on the GSF
  registers within 12 months of implementation

44
GSF - Advance Care Planning

• GSF template includes
• Thinking ahead
• - open questions
• - what matters to pt /
  carer
• - what to do and what not
  
• to do
• Proxy - who else involved (LPOA)
• Who to call in a crisis
• Preferred place of care death
• Other requests eg organ donation / special
  instructions

45
ACPs in care Homes

• Improved communication with residents and
  families early on
• Improved planning of care
• Reduced crises
• Helped formalise discussion using a tool
• Some gave to families, some senior nurses
• DNAR difficult- prefer Allow Natural death.
• Some found they were difficult discussions
• All liked having them useful and clear

46
Difficulties with ACPs

• Bring up the subject
• Communication difficulties
• Discussing options- ?unrealistic
• DNAR discussion
• Family tensions
• Staff resistance
• Updating them
• Communicating them

47
(No Transcript)
48
How do we cascade the information? - GSF Website

• 800 hits per day
• Information on GSF, resources and new
  developments
• Links to the online audit tool
• Plan to update for Autumn 07 with protected
  sections for registered practices, care homes and
  PCT facilitators/SHA leads

49
For more information on GSF

• National GSF team Judy Simkins - GSF / GSFCH
  Administrator
• Tel [phone]
• GSFCH LEAD Nurse - Nikki Sawkins
  nikki.sawkins_at_nhs.net
• Email
• info_at_goldstandardsframework.co.uk
• Website
• www.goldstandardsframework.nhs.uk
• NHS End of Life Care Programme
• www.endoflifecare.nhs.uk