Overview of a new study to assess the impact of hospice led interventions on acute use Jonathan Ellis, Director of Policy & Advocacy
The problem Almost 600,000 people die each year Half will die in a hospital bed, with increasingly complex needs Average length of stay for final hospital admission prior to death is 13 days at a cost of over 3,000 Around a third of people dying in hospital have no clinical need or preference to be there End of life care accounts for 20%+ of NHS spending
The role that hospices play Reducing avoidable admission to hospital e.g. single point of access for dying people, or hospice nurses in A&E to provide assessment and redirection of patients Facilitating rapid transfer from hospital e.g. providing support to hospital discharge teams, or additional hospice managed step down beds in hospices, care homes or community hospitals Supporting high quality care in other settings e.g. providing training and supporting care homes or domiciliary care services Providing home based care for people who wish to die at home e.g. 24/7 support to patients and families immediately on discharge from hospital
The research question What are the characteristics and critical components of hospice-led interventions that are effective, in terms of quality, outcomes and costs, in preventing avoidable admissions to hospital or facilitating appropriate and timely transfer from a hospital bed for people approaching the end of life?
HOLISTIC project phases Phase one Infrastructure and evaluation framework December 2016 to the end of February 2017 Recruitment of a project manager; the call for expressions of interest to participate in the study to hospices; the development of a criteria for site selection; and the development of the project methodology. Phase two Data collection and evaluation March to the end of July 2017 Data collection from selected sites, and site visits, and the development of an interim analysis of data quality. Phase three Final report and dissemination July to the end of November 2017 Analysis of site data; engagement with stakeholders on the development of supporting resources; a final report to NHS England in September; the publication of supporting resources; and the dissemination of the study findings
Project outputs 1. What works? There are X effective, generalisable hospice led interventions that can move people out of hospitals at the end of life 2. Enablers for success? Lessons learned included the success factors and challenges 3. Potential impact? If these interventions were implemented it would represent Y days not in hospital with Z impact 4. How to do it? For each intervention, this is what it is, and here s how to implement it in different settings
We will assess hospice led interventions Using inputs from around the country To answer several critical questions on end-of-life care Hospice innovations and experiences Nationwide databases: Hospital Episodes Statistics ONS Death registry Minimum Data Set (MDS) for Palliative Care Services Experts on healthcare, academia, and clinicians What interventions involving hospices are most effective and generalisable in keeping people out of hospital at the end of life? What could their impact be on the NHS, hospices, and the public? What are the lessons learned and how could the interventions be applied more broadly?
Study dimensions A B C Dimension Main outcome measure Evaluation of the target outcome Interventions and sites to test Hypothesis Proportion of last 90 days of life spent out of hospital (saved bed days) Quasi-experimental study assessing difference in differences between intervention and control settings Assess hospices and interventions to balance probability of finding effective interventions
Type of intervention 1 2 3 4 5 Introduce hospice EoL care discussion Entry into hospice care Prevent admission Facilitate discharge Intervention a) Improving perceptions of hospice a) Training of community ambulance staff b) Training of hospital clinicians c) Training of GPs a) Single point of access referrals b) Satellite clinics in areas of low referral a) Care/nursing home education b) 24/7 hospice at home service c) 24/7 helpline for service users d) Synchronising IT systems between providers e) Training of ambulance staff f) Specialist clinics and procedures g) Community service for less complex EOLC h) Home personal care provision a) Hospital based discharge service b) Discharge service delivering social care c) Hospice IP capacity expansion d) Nurse-led beds in the hospice for less complex hospital discharges Number of hospices 14 9 2 1 9 1 7 7 3 3 2 1 9 5 5 3 21 23 Total 1 125 (57 unique hospices)
Filtered by implementation date 2010-2016 Filtered by anticipated Type of intervention Number of hospices 1 Introduce hospice 14 14 0 Filtered for top 5 hospices 0 2 3 EoL care discussion Entry into hospice care 12 10 12 10 impact of intervention 1 0 9 per intervention 2 0 5 4 Prevent admission 67 60 50 19 5 Facilitate discharge 22 17 17 15 Total 125 (57 unique hospices) 113 (51 unique hospices) 76 (45 unique hospices) 39 (34 unique hospices)
Outline project plan 2017 2018 2019 2020 Jan Feb Mar Apr Ma y Jun Jul Aug Sep Oct Nov Dec Phase 1 complete Finalise ethics application Pilot one site visit Send recruitment emails to intervention and control groups, launch web-form Submit data requests to NHS-D Phase 2 Data gathering Site visits Interim data synthesis Phases 3 and 4 Analyse data Prepare report Prepare how to guides Hospice UK conference Launch engagement strategy Hospices and hospitals begin to implement proven intervention s Decreased hospital use at end of life across the country
For more information Jonathan Ellis Director of Policy & Advocacy j.ellis@hospiceuk.org 020 7520 8294 @hospiceukpa @hospiceuk