Proactive Anticipatory Care (PACe) in Guildford & Waverley
Introduction Sian Jones Clinical Lead End of Life Care & Cancer Guildford & Waverley CCG
Sharing our learning Background Putting it into practice A GP s experience Introducing our PACe documentation A Practice s experience Outcomes Ongoing aims and next steps Q and A
Background Quality Premium activity: December 2013 Focus on dementia patients in care homes Frailty Initiative: June 2014 Further promotion of care planning Integrated Care Partnership: April 2015 Wider programme of support for older people Target: 80% of nursing home residents to have PACe care plan (with upload to ambulance service s system IBIS)
What is PACe? Comprehensive patient-centered care planning document. Key element is situation specific decision tool. Guides appropriate action. Advisory, not legally mandated.
PACe usage Aimed at: People who have been diagnosed with a terminal illness (amber/red on the GSF register) i.e. with weeks or days to live People with a terminal diagnosis who want to be clear on their future care People living in nursing homes/residential care People living in the community with long term conditions where hospital admission may not offer clear benefit
When PACE works well Based around discussion with the patient, family, carers, care-workers, health professionals. Best interests perspective. Considers options and alternatives if, then.. but if, then... Comprehensive narrative.
When PACE works less well Poor patient and other engagement Poorly thought out, or poorly documented e.g. do not admit directive Documentation has not been updated. Off-radar poor prominence, not logged on ambulance service s system (IBIS), patient and carers/care-workers do not value importance
Putting it into practice Abigail Groves Senior Commissioning Manager End of Life Care and Cancer Guildford & Waverley CCG
Facilitating implementation of PACe Frailty Initiative funding. Discussion and education e.g. Frailty Forum. Care Planning Improvement Project. Responding to feedback and making implementation easier.
Care Planning Improvement Project Dec 2014 Mar 2015 Aims To promote care planning. To review the quality of the care plans in place. To analyse whether care plans are reducing emergency hospital admissions. To make suggestions for future improvements.
Method Part 1: Quality audit and user feedback GP surgeries and care homes Part 2: Outcome monitoring Emergency admissions to Royal Surrey County Hospital from care homes throughout 2014
Results Part 1: Quality auditing and user feedback Statement 1 There is clear evidence that there was a 1-1 and/or a family meeting when completing the care plan 2 The plan has been reviewed in the last 12 months 3 There is evidence of wishes expressed in DNAR decisions being included in the plan 4 There is evidence of wishes expressed in Advanced directives and Advanced care plans being included in the plan 5 Family members and key contacts are clearly identified within the plan 6 The patient s personal relationships are considered and the care plan reflects their contribution 7 The patient s spiritual and cultural beliefs are clearly recorded and evidenced within the care plan, and the plan incorporates care directives that reflect the patient s spiritual/religious/cultural beliefs where appropriate 8 There is clear identification of disability/hearing loss/visual impairment/learning disability/mental health problems, and these are incorporated into the plan Statement 11 The plan is recorded as SPN and/or on IBIS 12 There is clear identification of whether or not the patient has a Power of Attorney or IMCA, and their contact details are clearly recorded in the plan 13 There is a clear outline of who needs to be contacted in case of altered care need or for urgent decisions regarding care 14 The plan clearly records the patient s current health care requirements, diagnosis and medication list 15 The plan clearly identifies if the patient has capacity; and where the patient does not there is clear evidence of best interest decisions including carers or IMCA 16 The plan clearly states the key person responsible for the plan 17 The plan clearly identifies the levels of care and gives direction to staff regarding actions required across the patient s health care requirements (weighted scoring) 18 The information shared in the plan is agreed with the patient where they have capacity, where best interest is applied only current relevant medical information is shared in the plan 19 Plans are stored in accessible place but not for the members of the public to see 9 There is a clear list of all clinicians and other healthcare professionals involved in the patient s care 10 The plan is shared with all clinicians and other healthcare professionals listed previously 20 Where the patient has capacity there is explicit consent to the planning process and where best interest applies there is evidence of a best interest decision including IMCA as required
Results Part 2: Outcome monitoring avoidable admissions Data review of emergency admissions to the Royal Surrey County Hospital from care homes
Key findings Practices are engaging with the Frailty Initiative and understand the importance of good quality care plans. X Huge range in quality of the care plans in place, even within each individual practice. Data demonstrated a downward trend in emergency admissions from care homes throughout 2014.
Recommendations Areas for possible improvement with regard to care plan implementation: Consideration of frailty worker recruitment. Enhancement and computerisation of the PACe form. Education of patients and healthcare professionals.
CCG response Recent delivery improvements: o EMIS template o How to guides o Patient leaflet o Stationery o Repository on intranet Education Engagement and awareness raising
Example of targeted education Care Homes Forum o Prompt GP to complete a PACe if resident does not have one. o Prompt GP to update PACe if anything changes e.g. medication. o Ensure you/colleagues are aware of the existence of a resident s PACe care plan, and where it is held at the home. o Provide appropriate care in accordance with the resident s PACe care plan. o Send a resident s PACe care plan into hospital if he has an appointment or admission (and ask for it to be returned when the resident returns).
Engagement and awareness raising - secondary care Involvement of geriatricians o o Frailty Forums Locality meetings Close working with in-reach GP Education key messages o Start the conversation with patient and family. o Ask for PACe care plan when patient admitted. o If no care plan, flag on the discharge summary: GP please consider PACe. Audit of emergency admissions
A GP s experience Karen Jones GP Binscombe Medical Practice, Godalming
A GP s experience PACe document being used in our practice both in the community and in care/nursing homes. Best results seem to be from care/nursing homes where there is adequate support for patients on tap. Success in the community involves improved integration of care across multiple agencies.
A GP s experience Residential home shared with local practice with similar ethos. 64 beds, shared between practices. Mixture of private and social service funded beds, some respite. Dedicated care team but not nurses.
A GP s experience All permanent residents have PACe plan and DNACPR (as appropriate) in the home. These are completed 6-8 weeks after the residents have settled in to allow GP time to get medical records, review history etc and for staff to invite relatives in to meet GP.
A GP s experience Conversation with patient and relatives about future care. Best interest framework if patient lacks capacity. Takes about 45 minutes. Review of medical history. Review of medication. Any previous Advance Care Plans/Advance decision to refuse treatments/attorneys holding LPAs for health, etc.
DNACPR. A GP s experience Review of spiritual wishes; what used to make them want to get up in the morning. Religious beliefs and customs. Documentation and explanation regarding sharing of information and how this will help in out of hours situation.
A GP s experience Positives: Relatives like talking about their loved ones and are often relieved that they will be well cared for in the home, but referred to hospital if appropriate. Gives a clear sense to team and GPs as to where we are headed. Feels like good holistic medicine. Much more support for out of hours service. Care staff feel empowered to provide appropriate care especially out of hours.
A GP s experience Negatives: Time consuming. Need updating at least annually, but more frequently if clinically indicated. Despite filling them in, sometimes don t get transferred to hospital or come back out with residents. Not necessarily used by hospital when making decisions.
PACe Care Plan PACe document
Making a difference? Place of death 2014 2012 2011 Hospital 38% 45% 47% Care home 47% 32% 31% Home 11% 6% 19% Hospice 1% 2% 1% Other 3% 16% 1% Place of death for patients of Binscombe Medical centre
Making a difference? Gaining relatives feedback on end of life care: Bereavement letter 3/12 after patient s death. Standardised second paragraph with numbers for Cruse/local bereavement support.
Relatives feedback Yes it was good to have a unified approach with discussion about suitable care for Mum and a written plan for her file. I would ask that you would continue to do what you did for X... and most important keep this level of care going.
Relatives feedback I cannot say how much we appreciated the care and attention X was given It was a good opportunity to talk about what might happen in the future. It would have been nice to know what to expect at the end of Mum s life.
Actions from patient/carer/family feedback Leaflet explaining the PACe document in context of Advance Care planning. Relative leaflet about physiological changes at end of life.
A practice s experience Debbie Sampson Admissions Avoidance Liaison Coordinator The Mill Medical Practice, Godalming
Frailty project background for The Mill Patients Identified o all care/residential homes Planning our approach Outcome and next steps o Admissions Avoidance Liaison Coordinator IBIS
IBIS Data From 01/10/2014 To present The Mill Medical Practice Ibis Conveyance Rate Calls Per Patient Ratio Month Patients Matches Conveyed Non Conveyed Conveyances Avoided Admissions Avoided Oct-14 236 6 1 5 16.67 0.03 3.02 1.00 Nov-14 236 7 4 3 57.14 0.03 0.69 0.23 Dec-14 238 21 9 12 42.86 0.09 5.07 1.67 Jan-15 271 15 8 7 53.33 0.06 2.05 0.68 Feb-15 296 14 7 7 50.00 0.05 2.38 0.79 Mar-15 306 20 13 7 65.00 0.07 0.40 0.13 Apr-15 341 22 5 17 22.73 0.07 9.74 3.21 May-15 350 15 11 4 73.33 0.04-0.95-0.31 Jun-15 359 22 9 13 40.91 0.061 5.74 1.89 Jul-15 348 20 7 13 35 0.057 6.4 2.11 Aug-15 353 27 13 14 48.15 0.076 5.09 1.68 Sep-15 352 46 19 27 41.3 0.131 11.82 3.9
A patient s journey Frail, elderly housebound female. On lithium since 1996 for bipolar. Lithium dose reduced as toxicity. Became manic. Sectioned June 2011. During admission, needed surgery for faecal peritonitis. Discharged Dec 2011. On olanzapine post discharge. Put on weight, mobility declined, started to fall and become more withdrawn. Referred to falls clinic. Jan 2013 - Xray spine showing OA L 2-5. Admitted 9 days Feb 2013 for confusion and falls. Diagnosed UTI. Saw consultant Aug 2013 who said could do nothing with the back.
Hospital admissions Oct 13 Aug 14 Oct 13 Jun 14 6 periods of hospitalisation; only 18 nights at home 26/6/14-9/7/14 24/7/14-4/8/14 7/8/14 - Seen at home. Patient requested no more hospitalisation. Husband unsure how this could be achieved. 10/8/14-25/8/14
What changed Communication between GP and hospital Consultants. Husband happier with home carer package. Oct 14 - Patient agreed to PACe care plan, with support of family. Patient felt more in control. PACe detailed alternative plan to admission e.g. out of hours management of UTI. Agreed with DNs and consultant. GP felt patient could stay at home - multi-disciplinary approach. Jan 15 - discharged from Community rehab team with good personal action plans agreed. NO FURTHER ADMISSIONS since Aug 14.
The now Sian Jones Clinical Lead End of Life Care & Cancer Guildford & Waverley CCG
Frailty Initiative data Quarter 1 2015/16 1645 patients recorded on practice risk registers. 721 patients in nursing homes have a PACe plan (58% of the nursing home population) 559 (77%) of these PACe plans are on IBIS.
Headline outcomes for over 65s Linked to Integrated Care Partnership concepts: Programme of focused in-reach and case management for complex discharge Integrated locality services to actively support identified at risk frail patients Age UK Falls pathway Year-to-date summary as at month 5 (for age 65+) 14/15 15/16 Variance Year-to-date non elective spells 3333 3207-126 Excess beddays 3544 3234-310
Ongoing aims Increasing coverage of PACe plans. Increasing uploads to IBIS and out of hours system. Improving quality of documentation; ensuring info is relevant, up-to-date and comprehensive.
Quality assurance: Next steps o Further quality audits SECAmb, CCG o Practice visit questions: How are you assured of the quality of your PACe plans? What are you doing to ensure PACe plans are updated? Education, education, education
Any questions?