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Organisation develops a project to improve palliative care for older patients at the end of their life, upskilling untrained care home workers and improving patient wellbeing

Challenge

    • 58% of frail patients die in hospitals, despite their preferred place of death being home
    • £18.5m is spent annually on patients over 65 years of age due to unplanned admissions
    • Care home workers and primary care teams lack knowledge in managing end of life care patients
    • Provide supportive care home services for residents and upskill workforce

Action

    • Introduced the PACT project to deliver enhanced palliative care services for older patients
    • Delivered training to 482 care home workers and multi-professionals in advance care planning
    • Developed a 5-day PACT programme, incorporating coordinate my care (CMC) training for staff
    • Provided ‘is my resident well’ pocket guide and a training package for untrained care home workers

Result

    • Improved care home rating from amber to green
    • Resulted in skills improvement of staff and workers within care homes
    • Influenced care of 62 residents through advance care plans, with a 96% increase in CMC records

Synopsis:

Approximately 70% of people would choose to die at home. However, ONS data suggests, in Harrow, 58% are dying in hospital (compared to the national average of 49%) with care home deaths accounting for 13% (compared with the national average of 20%). The dedicated spend per annum related to the over 65 care home cohort is £18.5m, largely accounted for by unplanned hospital admissions. The PACT project proposed that possible reasons for this include:

- lack of knowledge and confidence of care home workers and primary care teams in end of life care,

- missed opportunities to engage in the advance care planning process and

- having no dedicated care home service to support residents to die at home should they wish to. Improving knowledge of what people want by upskilling the workforce on advance care planning and improving the communication of these wishes by using CMC, the only electronic platform accessible by primary and secondary care, palliative care services and paramedics goes some way to be able to prevent avoidable admissions to hospital. To further improve communication and reduce length of stay for admissions that are appropriate, the Sutton Homes of Care Vanguard red bag scheme was piloted.

Challenges:

Approximately 70% of people would choose to die at home. However, ONS data suggests, in Harrow, 58% are dying in hospital (compared to the national average of 49%) with care home deaths accounting for 13% (compared with the national average of 20%). The dedicated spend per annum related to the over 65 care home cohort is £18.5m, largely accounted for by unplanned hospital admissions. The PACT project proposed that possible reasons for this include:

- lack of knowledge and confidence of care home workers and primary care teams in end of life care,

- missed opportunities to engage in the advance care planning process and

- having no dedicated care home service to support residents to die at home should they wish to.

Improving knowledge of what people want by upskilling the workforce on advance care planning and improving the communication of these wishes by using CMC, the only electronic platform accessible by primary and secondary care, palliative care services and paramedics goes some way to be able to prevent avoidable admissions to hospital. To further improve communication and reduce length of stay for admission that are appropriate, the Sutton Homes of Care Vanguard red bag scheme was piloted.

Outcomes:

Challenges existed, including fluctuating attendance at care home training (overcome by repeating sessions). Despite this:

• 482 multi-professional attendees trained in advance care planning in 67 well evaluated educational events (233 hours, January-July 2018)

• 1.6 - 2.1-point increase (Likert scale 0-5) in End of Life Knowledge, Skills and Confidence scores (year 1) and 0.9-1.3-point increase (year 2) with newly developed 5-day programme in association with St Luke’s Hospice (delivered to further 7 care homes beyond the scope of the project).

• Care home rating improved from Amber to Green for end of life care by Harrow Council.

• Five-day programme delivered to 39 staff (14 completing entire 5- day PACT programme incorporating CMC training as part of ongoing work with Care UK to enable the first care home nationally to access CMC (requires NHS IG toolkit compliance).

- Recognising and Acting in Signs of Deterioration ‘Is My Resident Well’ Pocket guide, training pack and train the trainer programme developed for the NW London Collaboration of CCGs, with 31 trainers trained across 8 CCGs to deliver training to untrained care home workers.

• 62 Advance care plans recorded on CMC within the pilot period.

•PACT data used to guide Harrow Integrated care system development.

Spread:

The PACT project expanded beyond the original intended proposal to incorporate innovative training methods such as simulation training and development of the ‘Is My Resident Well?’ Pocket guide, training pack and train the trainer programme which has been widely publicised in care home newsletters by the NWL CCGs communications team. Being a HEE funded project we have shared our model widely, particularly within Northwest London largely via presentations and nationally via publications as detailed below: - PACT project presentations across NW London CCGs:

Brent, Hillingdon, Hammersmith and Fulham.

- Publication of innovative simulation training for care home workers in International Journal, Dementia.

- Margaret Butterworth Forum, Kings College London

- UCL Partners- Presentation

- Royal Marsden Partners and British Geriatric Society Conference posters

- HEENL Dementia Forum Presentation

- Oral presentation on health and social care integrated advance care planning on CMC at RCGP conference October 2018.

We have seen an increase in uptake within Harrow of CMC usage by 162% after 2 years and spread to neighbouring CCGs for example, Hillingdon CCG, who have implemented the use of CMC for all 980 care home residents by the end of March 2019 demonstrating the potential impact for improving proactive care.

Value:

Whilst our work has not demonstrated a reduction in avoidable admissions, (largely because community services are not aligned to support care home residents), we have managed to improve the communication of wishes by championing CMC and improve the skills of 482 care home workers and other multi-professionals in advance care planning.

The PACT project has directly influenced the care of 62 residents by creating their advance care plans, but has also seen a 96% increase in CMC records created by the end of year one and a 162% increase by the end of year two within Harrow CCG, because our model proved its value and became the mode of choice within Harrow and in neighbouring CCGs.

Our 5-day programme with innovative simulation training, involving actors and paramedics, has demonstrated an increased knowledge and confidence of care home workers and the wider multi-professional programme has too. Anecdotally, we have seen better advocacy for residents insisting on GP visits to support residents at the end of their life. Additionally, the ‘Is My Resident Well?’ pocket guide, which highlights the need to ensure decision making in a crisis is in keeping with resident’s preferred priorities, has been received with much enthusiasm.

Involvement:

The Harrow PACT project emerged as a result of a prior HEE project in 2014-5, the award winning ‘Challenges in End of Life Care’ multi-professional education programme. The resulting end of life champions that emerged, results in a proposal being submitted to Health Education England Northwest London by a multi-professional steering group, incorporating key stakeholders in the patient pathway from primary and secondary care as well as social care, consisting of:

- General Practitioners,

- Geriatrician,

- Consultant in Palliative Care,

- End of Life Care Nurse (London Northwest Hospitals NHS Trust),

- St Luke’s Hospice Single Point of Access Manager,

- London Ambulance Service Paramedic,

- Pharmacist,

- Harrow Council Safeguarding Lead,

- Care home manager,

- CCG Macmillan GP and

- Representative from the Residents and Relatives Association to ensure the patient and care home staff’s ‘voice’ was heard in development and delivery of the project. These stakeholders have been pivotal in both delivering education and supporting implementing guidelines and protocols to spearhead adoption of CMC use and red bag scheme roll out. These same stakeholders have now been enlisted to work to create a new integrated care system for Harrow using PACT data to support.

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