The North West End of Life Care Programme for Care Homes Facilitator - Alison Doyle 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 Markers For 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 theatre earlier mobilisation, reduced length of stay reduced readmissions. 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 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 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 ‘What is the right way?’ ‘Doing it right’ Simple Rules Clinical 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 Resident 2. The Family 3. 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?