End of Life care- Core Business for Geriatricians? BGS Conference Liverpool May 15 th 2016

Transcription

1 End of Life care- Core Business for Geriatricians? BGS Conference Liverpool May 15 th 2016 Prof Keri Thomas National Clinical Lead GSF Centre in End of Life Care, Hon Professor End of Life Care Birmingham University RCGP Clinical Expert End of Life care

2 Plan 1. Context and challenges in End of Life Care 2. Geriatricians and EOLC 3. Our experience from the GSF Centre - in community and hospitals 4. Future challenges and next steps

3 1. Context and challenges in EOLC Things are changing with our ageing population, increasing multi-morbidities, complexity + costs Frailty and multimorbidity are the biggest killers Over-use of hospitals Increasing Multi-morbidities Life span Poor care still happening Expenditures

4 End of Life Care in the News BG S Sp r in g Dying Matters week, CQC report

5 UK ranked top of the world in EOLC The time for incremental change is over - with the ageing population and the continued growth of chronic illness,the trends are not in our favour- we have to move swiftly!

6 GMC Definition of End of Life GMC definition - People are approaching the end of life when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with: advanced, progressive, incurable conditions general frailty and co-existing conditions that mean they are expected to die within 12 months existing conditions if they are at risk of dying from a sudden acute crisis in their condition life-threatening acute conditions caused by sudden catastrophic events. End of Life Care Supportive Care Palliative Care Terminal Care Death

7 Its about living well until you die! a good life to the very end

8 Bridging the Gaps Too few.. dying where and how they would choose given reliable care in line with preferences given proactive care earlier, helped to live well Too many. living and dying poorly dying in hospital - crises wasted expense bereaved relatives regretful

9 Inequity- Different ways of dying Rapid, erratic and slow dying trajectories- After Lynn Rapid e.g. Cancer GP has about 20 deaths / year Sudden death / Other

10 A new Tipping Point of potential over- medicalisation Just because we can doesn t mean to say we should - potential for over-medicalising A new paradigm time for a proactive approach.

11 Care in the Final Days of Life Earlier planning prevents crises in final days CQC in hospitals assesses care in the Final year Final days After death GSF Hospital Accreditation process approved by CQC as the only EOLC information source in hospitals

12 eactive to proactive Reactive Admitted after collapse Repeated admissions to hospital in last year revolving door No proactive thinking No advance care planning, no listening,no life closure discussion, no planning Crisis - worsens at weekend Readmitted Dies on ward alone Family given little support in grief - staff feel let family down No reflection by teams- no improvement Poor final stage of life Poor dying, poor family memories,inappropriate use of hospital Teams not satisfied gave best care Proactive Anticipatory proactive thinking Worsening condition recognised earlier Identify him as vulnerable for GSF register Proactive care in line with needs- coding Assess clinical and personal needs Advance care planning discussion + DNAR recorded and communicated space to listen Preferred to be at home, no heroics/treatment Plan community care with GP + out of hours +crisis prevention / rapid discharge Discharged home Crisis discussion with family + GP, ACP Hospital admission averted High quality care provided-dies at home Bereavement care for family Team reflection+ further improvement Better outcome for patient, family, teams, staff Most cost effective + best use of resources

13 2. Geriatricians and EOLC Overlapping areas in caring for ageing population Ageing Geriatricians GPs, Care homes+ others Declining End of life care Dying Specialist Palliative care Geriatricians End of Life care is core business for geriatricians!

14 End of Life Care Quiz 1. How many of your patients are likely to die this year? 2. How many are in their final year of life. a) In community? b) In hospital? c) In care home? 3. How many hospital admissions in their final year of life? 4. How many deaths in hospital could be at home? 5. Could you recognise/ identify these patients earlier? 6. Do you know their wishes/ offer Advance Care Planning discussions to all? 7. How many care homes/ wards/ practice teams doing GSF training/ accreditation in your area? Can you help them? 8. How often do your patients die?

15 Enabling generalists in end of life care 1) Specialists 2) Generalists - GSF 3) Lay People- general public Hospice and Specialist Palliative Care Workforce 5,500 Enabling Generalists Primary Care Care Homes Hospital Domiciliary Care Workforce -2.5 m Public Awareness Community Care Carers Support etc Population 60m End of Life care is everybody s business

16 Question What are the biggest barriers for you in identifying people earlier in the last year of life? Fear of others giving up on them? Loss of hope? Death seen as failure Sued or complaints etc

17 3. Our Experience at GSF Centre as a vehicle for change GSF is the leading Training Provider in End of Life Care in the UK enabling generalist frontline care providers to deliver a gold standard of care for all people nearing the end of life Every organisation involved in providing end of life care will be expected to adopt a coordination process, such as GSF DH End of Life Care Strategy July 08

18 GSF enables a gold standard of care for all people nearing the end of life 2. Depth 1.Spread Accreditation Quality assurance 6 Quality Hallmark Awards BGS co-badges our hospital programme GSF Quality Improvement provides full package of support for all settings 3. Joined-up Integrated Cross boundary care GSF can be a common language

19 Accredtation GSF Quality Hallmark Awards 10 GSF Training Programmes 10 programmes In all settings 6 GSF Accreditation + Quality Hallmark Awards Care homes GP practices, Hospitals Others developing a national momentum of best practice All- Annual Appraisals + 3 yearly reaccreditation

20 British Geriatric Society endorses GSF AH Training and Accreditation The BGS are delighted to work with the GSF Team to help drive up standards of care across the country by supporting the GSF accreditation process and Quality Hallmark Award for End of Life care in Acute Hospitals. In working together, we think this will help raise the profile of end of life care in hospitals, and support geriatricians and others to provide more proactive quality care for the 30% of hospital patients considered to be the final year of life. Martin Vernon BGS EOLC Lead

21 CQC Approval- GSF is the only approved Information Source in hospitals for EOLC Helps for CQC inspections Care in final year- identify the right patient -Key Ratio Communicating and Planning After Death care Assessing personal needs- ACP Supporting carers Care in Final days BHRUT CQC- EOLC Good (green) to outstanding (blue)

22 Geriatricians in care homes

23 ACP Dec 06 v 13 Gold Standards Framework and the Supportive Care Pathway Draft 7 Gold Standards Framework Advance Statement of Wishes The aim of Advance Care Planning is to develop better communication and recording of patient wishes. This should support planning and provision of care based on the needs and preferences of patients and their carers. This Advance Statement of wishes should be used as a guide, to record what the patient DOES WISH to happen, to inform planning of care. This is different to a legally binding refusal of specific treatments, or what a patient DOES NOT wish to happen, as in an Advanced Decision or Living Will. Ideally the process of Advance Care Planning should inform future care from an early stage. Due to the sensitivity of some of the questions, some patients may not wish to answer them all, or to review and reconsider their decisions later. This is a dynamic planning document to be reviewed as needed and can be in addition to an Advanced Decision document that a patient may have agreed. Patient Name: Address: DOB: Hosp / NHS no: Trust Details: Date completed: Name of family members involved in Advanced Care Planning discussions: Contact tel: Name of healthcare professional involved in Advanced Care Planning discussions: Role: Contact tel: Thinking ahead. What elements of care are important to you and what would you like to happen? What would you NOT want to happen? Proactive Care- GSF 3 Steps identify patients who may be in the last year of life and identify their needs-based code/ stage assess current and future, clinical and personal needs plan Living well and dying well GSF Prognostic Indicator Guidance identifying those who may be in the final year of life 1%,30%,80% Every appropriate person should be offered ACP discussions, mainly Advance Statements, by their usual/chosen care provider, which then becomes an action plan for quality of care. 100% 80% 60% 40% 20% 0% Place Home Hospital Thinking Ahead - Advance Care Planning Reducing hospital Admissions, deaths + crises Living and dying well in preferred place of care

24 identify Identify the right population GSF Prognostic Indicator Guidance identifying patients with advanced progressive decline/ disease who may be in the final year of life 1% of the general population 30% hospital population 80% care homes population Three triggers: 1. The surprise question Would you be surprised if this person was to die within the next year? 2. General Indicators for decline + comfort care/need 3. Clinical indicators Suggested that all patients on register are offered an ACP discussion

25 30% of hospital patients are in the last year of life Clarke et al These patients (30%) ca recognised early eg using GSF PIG Milnes et al, Geelong study

26 Surprise question Used of Needs based coding Use of Needs Support Matrices Identify Needs Based Coding A All - stable from diagnosis (years) B Unstable, advanced disease (months) C Deteriorating, exacerbations (weeks) D - Last days of life (days) E- Purple After Care A - Blue "All" from Diagnosis Stable Year plus prognosis B - Green 'Benefits' - DS1500 Unstable/Advanced disease Monthly prognosis C - Yellow 'Continuing Care' Deteriorating Weeks prognosis Years Months Weeks Days Patient and family needs at different stages D - Red 'Days' Final days of life Days prognosis Support from GP/ practice team Purple 'After Care' Support from others- SPC/ hospital

27 Identifying Gold Patients GSF registered or Gold patients identified from any area,included on electronic register given Gold card, information sheet can access help-line or Gold Line to coordinate their care treated as special

28 Suggested benefits of being a GSF/ Gold patient Explored during GSF Programmes Improved communication with colleagues eg Regular proactive review by GPs if on register More prioritised care eg at A&E, GSF Alert Flag on hospital system Improve proactive planning reduce crises Quicker access and response incl OOH Reduce hospital visits, readmissions, Better listening to preferences, more Advance care planning discussion offered + preferences known+ DNAR More involved in care, more control, improves patient choices Family preparation for decline Better proactive support for carers and family eg respite, In addition- Social More access to social benefits advice, DS other benefits Offered spiritual needs assessment Carers needs assessment Open visiting Free parking Reduced repeating information Helpline eg GOLDLINE for some Other benefits NB Note some possibility of negative effects in some circumstances?

29 assess Assess Clinical and personal needs Advance Care Planning Discussion Advance Statement to include Gold Standards Framework and the Supportive Care Pathway Draft 7 Thinking Ahead - Advance Care Planning Gold Standards Framework Advance Statement of Wishes The aim of Advance Care Planning is to develop better communication and recording of What is important to you? patient wishes. This should support planning and provision of care based on the needs and preferences of patients and their carers. This Advance Statement of wishes should be used as a guide, to record what the patient DOES WISH to happen, to inform planning of care. This is different to a legally binding refusal of specific treatments, or what a patient DOES NOT wish to happen, as in an Advanced Decision or Living Will. Ideally the process of Advance Care Planning should inform future care from an early stage. Due to the sensitivity of some of the questions, some patients may not wish to answer them all, or to review and reconsider their decisions later. This is a dynamic planning document to be reviewed as needed and can be in addition to an Advanced Decision document that a patient may have agreed. Patient Name: Trust Details: What do you want to happen? Address: DOB: Hosp / NHS no: Date completed: Name of family members involved in Advanced Care Planning discussions: Contact tel: Name of healthcare professional involved in Advanced Care Planning discussions: Role: What do you not want to happen? Who would speak for you? Contact tel: Thinking ahead. What elements of care are important to you and what would you like to happen? What would you NOT want to happen? ACP Dec 06 v 13

30 GSF Summary Statement on ACP Every appropriate person should be offered ACP discussions (mainly Advance Statements) by their usual healthcare provider which then becomes an action plan against which quality of care is measured. ACP Dec 06 v 13 Gold Standards Framework and the Supportive Care Pathway Draft 7 Thinking Ahead - Advance Care Planning Gold Standards Framework Advance Statement of Wishes The aim of Advance Care Planning is to develop better communication and recording of patient wishes. This should support planning and provision of care based on the needs and preferences of patients and their carers. This Advance Statement of wishes should be used as a guide, to record what the patient DOES WISH to happen, to inform planning of care. This is different to a legally binding refusal of specific treatments, or what a patient DOES NOT wish to happen, as in an Advanced Decision or Living Will. Ideally the process of Advance Care Planning should inform future care from an early stage. Due to the sensitivity of some of the questions, some patients may not wish to answer them all, or to review and reconsider their decisions later. This is a dynamic planning document to be reviewed as needed and can be in addition to an Advanced Decision document that a patient may have agreed. Patient Name: Address: DOB: Hosp / NHS no: Trust Details: Date completed: Name of family members involved in Advanced Care Planning discussions: Contact tel: Name of healthcare professional involved in Advanced Care Planning discussions: Role: Contact tel: Thinking ahead. What elements of care are important to you and what would you like to happen? What would you NOT want to happen?

31 Plan Plan Living Well and Dying Well Living well Enabling more to live well at home +reducing hospitalisation Dying Well More dying at home or where they choose Mean length of stay (in days) Hospital 4 All Baseline Follow up Reduced Length of stayaverage 3-4 days One hospital 15 days

32 70% 60% 50% 40% 30% 20% 10% 0% GSF Care Homes Percent of Lancashire North CCG deaths at home and in hospital 2009 to August 2013 GSF GP Practices % of home deaths %in hospital Aug Jul Jun May Apr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan Source: Primary Care Mortality Database, Public Health, Lancashire County Council *Provisional data, does not include patients outside LCC boundary GSF Ac Hospital

33 Culture changebetter listening to patients and relatives. Dr Kumar Consultant Geriatrician Stroke Ward Royal Lancaster Infirmary GSF Accredited ward GSF has given us the framework to engage with relatives and put things in place to ensure the outcome they want for their relative... I think the biggest change has been the culture change GSF is the framework that allows us to make that happen. The best bit is making sure that patients receive the care they want, where they want it, when and how they want it and the satisfaction they and we get from that.

34 GSF Acute Hospital Over 80 acute hospital wards 8 accredited wards with BGS Several whole hospital CQC approved information source GSF Community hospitals 15 hospitals accredited GSF Hospitals Identifying over 30% All Offered ACP All Offered ACP

35 Accredited Community hospitals Identifying patients early 31% to 66% patients identified 70% 60% 50% 40% 30% 20% 10% Cornwall Community Hospitals GSF CHA Accredited Identifying over 30% 0% AVERAGE Advance Care Planning Offered to over 90%patients Offering ACP discussions 120% 100% 80% 60% 40% 20% 0% Snapshot at Accreditation of the four wards. All patients offered at least initial advance care planning discussions - some full ACP completion Tarrant Falmouth Lanyon Willow Initial discussion PPC, DNACPR, Proxy Full ACP discussion

36 - About 2700 trained - About 200 /year accredited / reaccredited - 25% of all Nursing Homes 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% GSF Care Homes the biggest, most comprehensive end of life care training programme in the UK Place of Death Hospital death decreasing 1st time accredited 2nd time accredited 3rd time accredited Home Hospital Care Homes of The Year 2014

37 Aims of GSF accredited organisations GP practices (Rounds 1-4) Acute Hospitals Community Hospitals Care Homes accredited Attainment of GSF Accredited teams in different settings 1. Identify 2.Assess 3.Plan Living well Early recognition of patients- aim 1% primary care 30% hospital 80% care homes 70% patients identified (range 35-90%) 35% identified early (range 20-58%) Advance Care Planning discussion offered to every person 75% offered ACP discussion (range %) Decreased hospitalisation + improved carers support Halving hospital deaths, 72% carers support (15-100%) 45% identified 98% offered ACP Carers support 100% identified, 81% identified in dying stages It is possible - 4.Plan Dying well Dying where they choose using personalised care plan in final days 63% die where they choose 71% using 5P plan final days Identifying more patients 92% offered ACP Length of stay reduced More discharged home, discussion (range Carers offering support most ACPs, 80% 5Ps care final %) improved reducing hospital deaths, days plan more dying where choose More discharged home use 5Ps care in final days improved 97% 5Ps care final days plan 100% offered Halving hospital 84% dying where 95% uptake deaths+ admissions choose, 97% carer support 90% using 5Ps care plan

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39 GSF website- videos GSF in a Nutshell Hospitals Nutshell Your ideal care home Prognostic Indicator Guidance ACP guidance Accreditation Evidence and evaluations

40 4. Future challenges and Next Stepspopulation based integrated care What would you want for your mother?

41 CARE HOME GSF Care Homes Integrated Cross Boundary Care HOME GSF Primary Care and Domiciliary Care HOSPITAL GSF Acute Hospitals

42 Earlier identification of patients in final year of life better provision + access to GPs and nurses prioritised support for patient and carers + easier prescribing ACP & DNAR noted and recognised care homes staff speak to hospital regularly Vision of Integrated Cross Boundary Care Gold patients and GSF Heart of Gold projects Better assessment + ACP discussions offered Primary Care coding Collaboration with care home Care Home proactive planning of care referral letter recommends discharge back home quickly advance care plan preferred place of care documented Gold Patients Putting Patients at the Centre of Care Urgent care- Ambulance + out of hours care flagged and prioritised car park free and open visiting Others GSF patient identified and flagged on system, registered Acute Hospital Readmission- - STOP THINK policy and ACP EOLC Strategic planning, Locality Register Hospices Domiciliary care using same coding and planning Community hospitals assessment & preferences noted Rapid Discharge Better discharge collaboration with GP using GSF register

43 Public Awareness Gold Standards Framework and the Supportive Care Pathway Draft 7 Thinking Ahead - Advance Care Planning Gold Stan dard s Fra mew ork Adv ance Stat eme nt of Wish es The aim of Adva nce Care Plan ning is to devel op bette r com muni catio n and recor ding of patie nt wish es. Dying Matters

44 Your country A Call to Arm This is an important time for geriatrics

45 Key Points There has never been a more important time for geriatricians in End of Life Care! With our ageing population, broadened definition of EOLC, most dying of frailty/multi-morbidity over 65, overmedicalisation we need a big vision of proactive populationbased care Practical take-home points more proactive care -identify, assess, plan care earlier EOLC is core business for geriatricians- call to arms!

46 Companions on the Journey Gold Standards Framework

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48 Introduction to GSF Accredited teams and GSF BGS Quality Hallmark Awards Julie Armstrong Wilson Nurse Lead Hospitals GSF Centre

49 GSF Hospitals training programme Option of an Open or Commissioned programme 6 workshops over 2 years Identify Assess Plan - living well Plan - dying well Evaluation pre and post training Organisational level Patient level Staff level

50 GSF Accreditation process Part 1: Outcome measures- Summary of key outcomes Part 2: Comparative Audit- measuring change before and after: Patient ADAs (deaths and discharges) Organisational Staff Part 3: Portfolio of evidence Portfolio demonstrating attainment of the GSF 5 standards Part 4: Assessment - Visit from The GSF Assessment team

51 GSF Accredited hospital wards Information is then presented to a panel of independent experts, including BGS representative who make the final decision of PASS or DEFERAL The wards receiving the Quality Hallmark Award today are: Sunrise B Queens Hospital, Romford Ward 6 - Airedale General Hospital Ward 9 Airedale General Hospital, Keighley.

52 Example of results from the accredited teams

53 Cumulated accredited wards identification rates from 8 wards in 4 different hospitals Average identification rate 32% More in oncology and care of elderly Fewer in haematology and renal

54 GSF BGS Hospitals Quality Hallmark Awards Awards Presented by BGS Hon Sec Andrew Williams Sunrise B Queens Hospital, Romford Ward 6 - Airedale General Hospital Ward 9 Airedale General Hospital

55 Well done!!