Midlothian Gold Standards Framework Care Homes Step Down Sustainability Project(September 2009 - September 2011)

Barbara Stevenson CNSRhona Moyes CNS

Background to Sustainability Project

• Commenced in March 2007 (18 month project led by J. Hockley, J. Watson and S. Murray from the University of Edinburgh)

• Seven Care Homes in Midlothian, Primary Health Care Teams and specialist palliative care

• GSFCH framework

Education

• Key champion appointed in each Care Home

• Attended facilitative learning course and GSFCH network workshops

(Foundations in Palliative Care for Care Homes, Macmillan 2004)

• Responsible for cascading training down to their ownStaff

Implementation of systems• Supportive palliative care register (ABCD register) • Adapted Liverpool Care Pathway (LCP) for the last days of life

Project OutcomesSignificant improvement in:• Care of the dying• Control of symptoms• Continuity of care• Carer support• Continued learning

Increased confidence in:• Communicating with relatives about death and dying• Caring for a dying person

Use of the ABCD Register with the GP

Outcomes cont.

• Increase in DNACPR status (8% to 71%)

• Increased explicit decision making in end of life care (4% to 55%)

• Fewer deaths in hospital (15% to 8%)

• A reduction of inappropriate hospital admissions (>40%)

Key Recommendations

• Advanced care planning discussed early in the admission – Communication and decision should emphasise the

appropriateness of allowing a natural death

• DNACPR status addressed on admission to a Care Home

Recommendations cont.

• Specialist palliative care support for residents with complex needs

• The use of symptom assessment tools

• The adapted Liverpool Care Pathway (LCP) used for all residents for end of life care

Recommendations cont.

• Organised reflection times following a death (Significant Events Analysis tool)

• Palliative care education for all Care Home staff

• Accreditation status of Care Home with GSFCH programme

The Step Down Project (September 2009 - September 2011)

Support Care Home Managers to:

• Continue palliative care education

• Consolidate and embed the GSFCH Framework

Step Down Project cont.

Education

• Induction

• Delivery of Macmillan Foundations in Palliative Care programme

• Develop communication skills

• Assist in complex family situations

Step Down Project cont.

Systems

• Support staff with the ABCD Register and attend the monthly GP reviews

• Encourage and support staff to use validated symptom assessment tools and adapted LCP

• Encourage the use of the Significant Events Analysis

Step Down Project cont.

Evidence• Collate end of life data

• Collate education programme evaluation and attendance data

• Support Care Home Managers to develop and gain GSFCH accreditation

After death data Jan to June 2010 Total number of deaths - 39

• Preferred place of death 36

• Place of death CH - 30 H - 9

• Inappropriate admissions 0

• DNACPR 34

• Advanced care planning 38

• ePCS 36 (Electronic Palliative Care Summary)

• LCP 21

• Anticipatory prescribing 20

• Assessment tools 10

• External support (CNS) 2

• Bereavement support 36

• Significant Event Analysis 15

Education Data Jan- Aug 2010

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Induction

Comm

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Bereavement

Pain and symptom

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Shadowing

Trained Staff

Care Assistants

CH Managers

Challenges To Date

Staffing• Loss of key champions

• Staff turnover

• Management changes

• Cultural differences

More Challenges

Education• Delivering educational content for trained and untrained staff

• Time allocated for education

• Development of communication skills

• GSFCH systems for use with younger residents

• Embedding the use of the significant events analysis

......and finally

Difficult but achievable

• Requires commitment from both sides

• Involves ongoing education