West Kent CCG Emergency Health Care Plan 20 October 2015 Bruno Capone
Local situation 11486 Elderly 85+ 3800 Care home residents in West Kent area Average life expectancy of nursing home residents is 6-9 months (care home residents around 2 yrs) 1200 admissions each year from care homes 2800 A + E attendances each year from care homes Around 50% of our local 85+ yrs die in hospital Frail elderly are likelier to die in hospital than cancer patients Successful CPR of care home residents is < 1% 1. Seymour J Do Nursing homes for older people have the end of life care support they need; Pall Med 2010 (225) 125-138 2. http://www.ageuk.org.uk/documents/en-gb/factsheets/later_life_uk_factsheet.pdf?dtrk=true 3. https://kar.kent.ac.uk/762/1/chop2.pdf 4. West kent CCG data 5. http://www.endoflifecare-intelligence.org.uk/profiles/ccgs/place_of_death/atlas.html 6. Resuscitation audit MTW 2013
West Kent Frail Elderly Model PROACTIVE MODEL OF CARE REACTIVE MODEL OF CARE WELL FRAIL ELDERLY PATIENT ACTIVE CASE FINDING Falls Delirium Incontinence Mobility Residential or nursing home resident GP ACUTELY UNWELL FRAIL PATIENT AMBULANCE DISTRICT NURSE INITIAL ASSESSMENT within 1 hour to assess Medical & risk assessment, place of management, care plan review FRAILTY REGISTERS MDT Unknown Patient PRISMA & CLINICAL JUDGEMENT TO FURTHER IDENTIFY PATIENTS Patient known and on a frailty register COMPREHENSIVE GERIATRIC ASSESSMENT & CARER S ASSESSMENT Stay at home with appropriate support Bed based intermediate care Acute Trust / A&E / Acute frailty unit CGA commenced immediately (Senior Review within 24 hours of first contact 7 days a week) Identification and optimised of medical issues Onward referral to specialists Goal setting Anticipatory care planning & medication review Start of discharge planning process Ongoing care provided in the most appropriate location Hospice Mental Health Unit GP / Geriatrician Nurse Physiotherapist OT Social Services INDVIDUALISED CARE AND SUPPORT PLAN AND CARER S SUPPORT PATIENT REVIEW Hospice Mental Health Unit Nursing / Residential Care HOME WITH APPROPRIATE SUPPORT Bed based intermediate care (7 days a week) Specialist ward in acute trust (7 days a week) Discharge to assess as soon as medically fit Care plan updated
West Kent CCG aspired outcomes for care home residents Giving the right care at right place at the right time 15% reduction in number of people at EOLC being admitted in hospital inappropriately Increase 15% in number of patients dying at their normal place of residence Reduction 15-20% inappropriate care home admissions
Top 5 symptoms and diagnosis 1 Falls 2 Unwell 3 Pain 4 Injury 5 Stroke TIA presentation at A+E 1 No diagnosis made 2 Fracture 3 UTI 4 other respiratory conditions 5 nothing abnormal detected
Care plan Confusion Advance Decision to Refuse Treatment Advance Care Plan Anticipatory Care Plan Admission avoidance Care plan Mental Health Care Plans Dementia Care plans Asthma/COPD/Heart-failure Care Plans
Ideal Anticipatory Care Plan Easy to read Applicable to situation when important decision needs to be made Made by someone who you can trust Evidence that plan is made in partnership with patient and family Easy accessible
Why a different ACP We wanted a document Easy to read lay out Easy to complete with minimal duplication A name that indicates the purpose of it Gives a sense of authority
DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION Name Address Date of birth Adults aged 16 years and over Organisation LOGO/name Telephone number Date of DNACPR order: / / NHS & Hospital numbers / DO NOT PHOTOCOPY 1 2 In the event of cardiac or respiratory arrest no attempts at cardiopulmonary resuscitation (CPR) will be made. All other appropriate treatment and care will be provided. Does the patient have capacity to make and communicate decisions about CPR? If YES go to box 2 If NO, are you aware of a valid advance decision refusing CPR which is relevant to the current condition? If YES go to box 6 If NO, has the patient appointed a Welfare Attorney to make decisions on their behalf? If YES they must be consulted. All other decisions must be made in the patient s best interests and comply with current law. Go to box 2 Summary of the main clinical problems and reasons why CPR would be inappropriate, unsuccessful or not in the patient s best interests: YES / NO YES / NO YES / NO 3 Summary of communication with patient (or Welfare Attorney). If this decision has not been discussed with the patient or Welfare Attorney state the reason why: 4 Summary of communication with patient s relatives or friends: 5 Names of members of multidisciplinary team contributing to this decision: 6 Healthcare professional completing this DNAR order: Name Position Signature Date Time 7 Review and endorsement by most senior health professional: Signature Name Date Review date (if appropriate) Signature Name Date Signature Name Date
Emergency Health Care Plan DO N CARDIOPULMONAROT ATTEMPT CARDIOPULMONARY RESUSCITATION This Emergency Health Care Plan is an advisory document that gives details about an agreed plan of care should this patient become unwell. Please use this information in conjunction with your assessment of the immediate situation to aid decision making in the event that this patient s health has deteriorated. Patient s Personal Information Name DOB Address Postcode NHS Number Contact Telephone Number Next of kin/other parties involved in EHCP development (with relevant party s consent) Next of Kin Any other parties involved i.e. friend Emergency Health Care Plan Copy of plan to be included in patient s notes along with the Personalised Care Plan and DNACPR if applicable. GP Practice (Office hours-bypass or emergency number) Information for person dealing with emergency Capacity Assessment Does the patient have capacity to make and communicate decisions about their medical care? If no, then are they likely to regain capacity? - If yes then please delay decision until capacity regained. If no, does the patient have an appointed Lasting Power of Attorney (LPA) for health and welfare or Court Appointed Deputy to make decisions on their behalf / advance decision to refuse treatment/advance statement? If yes then please include with emergency health care plan. If the patient lacks capacity then this plan should be formulated in their best interests in consultation with family/friends if possible. Name: Tel: Name: Tel: Service Contact Details Name of usual GP: Practice: Tel: Out of Hours GP Tel: NHS 111 Enhanced Rapid Response Team Via GP or NHS 111 Hospice in the Weald Tel: 01892 820500 Heart of Kent Hospice Tel: 01622 792200 Other relevant services: E.g. Community/specialist teams Yes No
West Kent CCG ECHP implementation GP VMO Scheme withdrawn 300K Reinvested in primary care to support care homes and GPs 150K was set aside for ECHP. GPs could earn 80 per plan. Aspiration is to get ECHP for 1000 residents produced 150K for proactive care home team to support 20 care homes with aim to provide proactive care and some reactive care
Process of implementation Sign up via LES/LIS 2 PLT events to share learning, focus on top 4 reasons of admissions Signposting to online resources 40% of care home residents to have a plan 50% practice have signed up
Electronic Care Plan system To be used for care planning and to share live GP data Web based system Aspire to integrate with GP and other health care systems Started April 2014 First year cost 1 mln+
Example CMPS
CPMS Video
CPMS Time Line
CPMS Progress 852 Admission Avoidance Plans uploaded Plans are shared with KCC, KCFT, SECAMB, MTW, KMPT, HOK
Lessons Learned GP engagement /GP Care Plan Fatigue Education and Training Working with Care homes Sharing of Care plans
Where are we now?
Any Questions?