24 Hour End of Life Care Coordination Centre Commissioner Lead

Transcription

1 Service Specification No. 5 Service 24 Hour End of Life Care Coordination Centre Commissioner Lead Paul White, Bromley CCG Provider Lead Heather Richardson and Shaun O'Leary, St Christopher s Period 1 st April 2014 to 31 st March 2017 Date of Review April Population Needs National/local context and evidence base The London Borough of Bromley has an estimated population of 312,580 people 1, with a higher than average older population and approximately 2,600 deaths each year. Of these 20 25% will die suddenly, leaving 80% dying predominantly of cancer, respiratory or cardiovascular disease. Bromley also has a higher than average number of death from dementia, 21% as opposed to a national average of 17.3%. This is statistically significant as end of life care has been shown to be more challenging for dementia patients and they experience a lower rate of home deaths and, in general, poor end of life care. The palliative care needs of residents of Bromley are likely to increase in time as it is estimated that the population will grow by 14% by 2021, this is faster than the UK average growth of 9% for the same time period. This population growth is coinciding with demographic changes occurring across the UK as a result of the ageing baby boom population which will mean that the number of people residing in Bromley that will require end of life services is set to increase rapidly over the coming years. Bromley also faces a unique challenge for the palliative care needs of its ageing population and there is some evidence that residents are currently not satisfied with the level of care that they are receiving 1. NHS England s outcomes benchmark and support packs show that Bromley is one of the worst performing areas in England in terms of patients rating of the out-of-hours GP provision. Identification of end of life care patients is important in ensuring they receive the right coordinated care from all different service and that their care preferences are recorded and communicated to the variety of care providers that they may encounter. For this reason many areas have begun to keep End of Life Care registers of patients who are nearing the end of their life. There is evidence to show that Bromley may not be recording their palliative care patients effectively. This is supported by the data shown below. The chart shows that Bromley has much lower percentages of deaths recorded on a palliative care register than the other boroughs in South East London. This includes both deaths with and without palliative care needs. Of the 56% of people in Bromley who die in hospital, there is an in balance in terms of diagnosis. Over a five year period, people with cancer were much less likely to die in hospital than people with other conditions. (43% cancer and 65% other conditions). 1 End of life care intelligence network, Bromley Local Authority profile, 2012

2 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Bexley Bromley Greenwich Teaching Lambeth Lewisham South East London Total Southwark UK Total % of deaths with PC need on a PC register % of ALL deaths on palliative care register Source: Marie Curie End of Life Atlas The Results of the first national VOICES survey of bereaved people showed that SE London had comparatively low results on most of the following end of life measures: Overall quality of care across all services by CCG Clusters Co-ordination of care while patient was at home Co-ordination of care: hospital with GP/community services Dignity & Respect shown by doctors all of the time last 2 days Dignity & Respect shown by nurses all of the time last 2 days Support for carers able to discuss worries with GP Pain management in the last two days Patient involved in decisions re: care as much as wanted Patient expressed preference where would like to die Respondent considered patient died in the right place Support for carers while patient at home Research shows us that if given the choice, most people would prefer to die at home and the least preferred place of death is in hospital. Rates of hospital deaths in Bromley remain round 56% with only 36% dying in their own home (incl. care homes) 1. The major limitation of the current end of life provision is not being able to exploit the benefits (both financial and human) which derive from early referral and the potential for more integrated and coordinated health and social care. Amongst these benefits are: Avoidance of hospital admissions A smooth and speedy transition from hospital to home Increasing further patient and carer satisfaction A link to a wider population which offers the added value of community engagement and of a bespoke volunteer programme The benefits of getting all care in one go in one place a one stop shop approach. We know that working with multiple agencies saps people s care giving capacity and energy. Also the benefits of one key person knowing someone s story patients and carers not having to repeat themselves

3 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Domain 2 Domain 3 Domain 4 Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill-health or following injury Ensuring people have a positive experience of care Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm 2.2 Local defined outcomes What are the expected outcomes of the new service? 1. In the first year of operation we will achieve a home death rate of 50% for those who are referred to the co-ordination centre. 2. National data has demonstrated that most people in their last year of life have an average of 3 hospital admissions. We would monitor this with the expectation that in Bromley we would achieve an average of 2 or less. 3. We will use an outcome tool to monitor satisfaction and impact of the new centre. 4. We would anticipate that 75% of patients referred to the centre would rate the difference the services provided by the centre to have made a positive difference. 5. We anticipate net savings for the CCG The parties will also evaluate the project using quantitative and qualitative methods, making use of well-established tools where possible. Performance will be monitored Quarterly. Quantitative methods: No. of patients referred No. of patients whose details are entered onto CMC No. of patients assessed, where referred from. No. of patients who die at home/care home/ in hospital/in hospice. Total no. of hospital admissions during contact period. No. of patients receiving support from Community Support Volunteers Qualitative methods: 1. A validated tool ( SKIPP) will be used 2. Patients receiving the Community Support Volunteer service will be asked to complete a short feedback questionnaire (already in use) about this service 3. Patients receiving social care and night sitting service and their informal carers will be asked to complete a short feedback questionnaire covering the following: Perceived reliability and helpfulness of worker Dignity and respect Responsiveness to individuals needs Communication (and coordination of care) 4. Summary of ad hoc feedback received (compliments/complaints/comments)

4 3. Scope 3.1 Aims and objectives of service The service aims to radically redesign the end of life pathway in Bromley offering a new commitment to end of life care in the local community. 3.2 Service description/care pathway The service is hosted and managed by St Christopher s Bromley and focusses on referrals for anyone who is eligible to be on the GSF/CMC registers. The referral form will be available for GP s on EMIS, other health care professionals can send an electronic referral form to Bromley Care Partnership. The centre ensures that health and social care services do not work in silos and that the patient and family experiences timely and co-ordinated care. Case-finding the extra 800 patients - this is to be achieved in the following ways: From those referred into the St Christopher s rapid hospital discharge pilot (to include PRUH and other hospitals, where the patient is a Bromley Resident) From the St Christopher s Group Clinical Nurse Specialists who currently attend Primary Care/GSF/Nursing Home meetings. These meetings are fundamental to achieving joined-up care. The CNS s will case-find the non-specialist population via these meetings The St Christopher s Group will shortly be launching a palliative heart failure service across Bromley. This is a research study/service evaluation and will be working with Bromley Health, the CCG and the PRUH. Academic support is being provided by the Cicely Saunders Institute, Kings College London University. This new service will be able to identify another group of people in the last year of life The St Christopher s Group works closely with Bromley Health and is re-configuring services in line with the newly developing Integrated Teams. Within this they will also have contact with the specialist nurses in COPD and Heart Failure who will be another source of case identification More specifically the new centre: will ensure that each referral to the co-ordination centre will have an assessment by a nurse experienced in end of life care. This will be agreed as a joint visit with a district nurse or community matron, for example, if they are already involved with the referred patient. The assessment will include a medical/nursing assessment, medication review, advance care planning and conversations re: preferred place of care/death and DNACPR. A carers assessment will also be completed. following the assessment a decision will be made as to who the most appropriate key worker will be. This decision will be made in consultation with the nurse attending the joint assessment will therefore ensure that all patients referred will receive the appropriate care package and professional support at the right time will enter patient s details, with their consent, onto the CMC register and the register will be kept up to date will ensure feedback to primary care GSF meetings of the clinical picture of their patients by centre staff or via one of the partners will reassess the patient 3 monthly either together with the named keyworker or by telephone, once on the co-ordination centre register will ensure the delivery of a personal care service up to six weeks for discharges from the PRUH and continued personal care for CHC patients (One year pilot project funded by the Reablement Board) will have regular contact to optimise joined up delivery of care and to encourage social carers to feedback any concerns or changes they have observed in the patients. Training will be offered by the Coordination Centre.*** will organise Marie Curie night nursing

5 will have a direct link with MEDIQUIP equipment services and will administrate the ordering of equipment for patients referred, including timely collection of equipment will have a strong link to Bromley Health Care, including community nursing and therapists. will have a strong link to the Local Authority and Social Services and OXLEAS (regarding the management of end stage dementia) will work directly with the St Christopher s Group specialist community services and ensure that patients are referred into these services at the appropriate time will have access to St Christopher s bespoke volunteer support service. will be able to respond rapidly to patients whose condition has changed and a reassessment needed 3.3 Population covered Registered population of Bromley GPs. 3.4 Any acceptance and exclusion criteria and thresholds To accept those people in the last year of life only 3.5 Interdependence with other services/providers (This is shown in the following diagram)

6 Bromley Healthcare DN s, Community Matrons, Integrated Team, LTC Team Bromley CCG Bromley Social Services Bromley Care Partnership Princess Royal University Hospital Hospital Palliative Care Team Liaison with Geriatricians, PACE, Discharge Coordinators Rapid Hospital Discharge Project (one year pilot funded by Reablement Board) to ensure quick discharge from acute setting; to provide Co-ordination Centre managed by St Christopher s Group Co-ordinates and directs care to include: Nursing/medical/social/carers assessment Medication review Discuss ACP/PPC/PPD/DNAR Review equipment needs & order AA/DLA via Bromley pension services/ds1500 from GP Referral to Integrated team as necessary (Physio, OT, DN, Diabetes team) Leave explanation of service- advice only in emergency OOH. If clear intro Keyworker (Community Matron/DN/COPD). If not clear re Keyworker explain at next contact Consent for CMC/Admin to add demographics/cns to add clinical details St Christopher s Bromley Community Specialist Palliative Care Team Providing specialist palliative care support Nursing and Residential Homes Implementing and sustaining the GSF programme in nursing care homes moving into residential care Other partners: Carers Bromley OXLEAS MEDIQUIP Age UK Planned night care service Managed by St Christopher s Bromley 10pm 7am Alzheimer s Society 4. Applicable Service Standards 4.1 Applicable national standards (e.g. NICE) St Christopher s Bromley is working closely with the London Cancer Alliance. It has collaborative links with national bodies such as Help the Hospices and the National Council for Palliative Care. The Chief Executive is a member of the Department of Health s End of Life Care Strategy Implementation Group. 4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges) 4.3 Applicable local standards 5. Applicable quality requirements and CQUIN goals 1.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D])

7 1.2 Applicable CQUIN goals (See Schedule 4 Part [E]) 6. Location of Provider Premises The Provider s Premises are located at: Caritas House Tregony Road Orpington Kent BR6 9XA 7. Individual Service User Placement