East Sussex Older Peoples' Residential &

Nursing Care - Provider Forum

22nd May 2012Kay Muir, East Sussex PCTs /CCGs Programme Lead for EOLC

Sophie Clark,Older Peoples Strategic Commissioning Manager, East Sussex County Council

East Sussex

What we will cover today

• The big picture – nationally and locally• The training and support available• Overview of EOLC Care Home in reach

service piloted in 2011/12 • Findings ASC e-learning pilot 2011/12• The benefits and rewards• Next steps• Questions

East Sussex

Where we are now• National and local drivers for change

– National strategies to support improved EOLC– Rising needs and expectations– Integration between health and social care– Regulatory requirements and quality standards– An identified need for training and support

• Workforce development plans• Resources for workforce development• A joint approach to workforce and end of life

care in East Sussex

East Sussex

Starting theconversation

Assessment andcare planning

Coordination of Care for the patient

Delivering high quality care

Last days of life

Care after death

•Open, honestcommunication• Identifying triggersfor discussion• Listening to cuesfrom patients

• Assessment and regular review ofpatients’ needs• Care planning• Assessing carers needs

• Coordination of individual patient care• Register-information shared across all sectors

• High quality careprovision in all settings

• Rapid response services

• Hospital, community, carehomes, hospices, communityhospitals, prison, secure hospitalsand hostels

• Ambulance Services•All OOH services

• Spiritual care

• Identification ofthe dying phase

• Review of needsand preferencesfor place of death

• Support for bothpatient and carer

• Recognition ofwishes regardingresuscitation andorgan donation

• Timely verificationand certification ofdeath• Viewing of thebody/mortuaryfacilities• Return of property• Care and supportof carer andFamily

The End Of Life Clinical Pathway

Coordination of Care for carers

National EOLC Core Competencies“Developing End of life Care Practice: A guide to workforce development to support social care and health workers to apply the common core principles and competencies for EOLC” 2012

A framework of competences, values & knowledge • Communication skills • Assessment and care planning • Advance care planning • Symptom management: maintaining comfort and wellbeing • Overarching knowledge and values

http://www.endoflifecareforadults.nhs.uk/publications/corecompetncesguide

East Sussex

EOLC National Occupational Standards

A framework of National OccupationalStandards 2009 to support common corecompetences and principles for health and social care workers working with adults at the end of life

Web:http://www.endoflifecareforadults.nhs.uk/publications/corecompetencesframework

East Sussex

Where we want to be - routes to success …

• More patients having a “good death” in their preferred place of care

• Fewer complaints about end of life care from relatives or friends

• An improved reputation for the provider

• Fewer unplanned hospital admissions

• A skilled workforce with improved morale and retention

East Sussex

East Sussex End of Life Care Home PilotQuality -high quality service to identify people at the

end of their life and support them to be cared for and die in their preferred place of care

Innovation - Piloting initiative at a local level

Productivity - reduction in inappropriate admission to hospital

Performance - evidence of people being cared for and dying in their preferred place of care - monitoring though activity and costs data

e.g. “Death in Usual Place of Care indicator”

East Sussex

EOLC Care Home Support Pilot Project

What the project involvedTwo multi-disciplinary EOLC support teams, provided across East Sussex by St Michael’s and St Wilfrid's Hospices, with the overall aim of supporting EOLC within care homes, to reduce avoidable EOLC hospital admissions and to enable residents to be cared for in their preferred place of care.

Year 1 project summary• 20 Care Home , 11 are residential and 9 nursing homes with a combined 714 residents. These Homes were

identified as having a high number of emergency admissions to hospital using urgent care data.

Progress to date• The EOLC Care Home support has been very well received in the community setting by the Care Homes

involved . • Baseline assessments were been completed and an action plan including training for each home was agreed

to meet the care home identified needs. • Training package for each of the care home commenced in September 2011 to Feb. 2012. The outcomes of

the training and comparison against baseline activity and behaviours are being completed,

Plans for 2012/2013• Project extended to inform health and social care commissioning in the future• Lot of learning about selection of care homes for 2nd year• Dissemination of year 1 outcomes and recommendations to inform commissioning intentions for 2013/14• Longer term aim for joint health and social care facilitator roles to support homes

East Sussex

St Michaels’s Hospice- Overall General information•Total No of Care Homes 10 : 6 Residential home and 4 Nursing homes•Total No. of residents: 347•Types of residents supported include : elderly, epilepsy, Parkinson's, stroke, hearing/speech/visual impairment, dementia, learning disabilities, CVI, Cancer, MS, mental health and heart failure

Summary of After Death Analysis (June to Sept 11)1. Of the 25 collected 11 residents died in hospital, and 14 remained within the

care homes.2. Evidence of PPC recording in 8/10 homes3. DNACPR now starting to be addressed in 9/10 homes where appropriate4. LCP being used in 3/10 homes

EOLC Assessment Questionnaire Summary and update for EOLC tools The education programme delivery is between September and December, 2011. The initial EOLC Assessment Questionnaire / use of EOLC tools undertaken ( in May /June) and repeated Spring 2012 to allow time for support following the educational input.

Issues identified during Stage 2:• GP refused to initiate LCP as dying patient did not have cancer• Lack of managerial support and attendance for EOLC training in some homes• Managers are finding it difficult to release staff to attend training sessions • Language barrier to training for some staff• Most homes are receptive to training • Staff are now actively approaching GPs for DNACPR/ JIC box• Evaluations of session 1 of training very positive• Session 1 attended by 74 staff, of which 8 were care managers/trainers

Summary of the 10 Pilot Care Homes

East Sussex

St Wilfrid’s Hospice - Summary of the 11 Pilot Care HomesOverall General information•Total No of Care Homes 11 : 5 Residential homes,5 Nursing homes and one dual registered home•Total No. of residents: 367 Types of residents supported include : elderly, epilepsy, Parkinson’s, stroke, hearing/speech/visual impairment, dementia, learning disabilities, cancer, multiple sclerosis, mental health and heart failure

After Death AnalysisFurther after death analyses will be completed at the planned focus group following completion of the

education package

EOLC Assessment Questionnaire Summary and update for EOLC tools •The education programme delivery is between September and Jan 2012. The initial EOLC Assessment Questionnaire / use of EOLC tools undertaken (in May /June) therefore not repeated until 1 month after completion of the training to establish any changes to practice and any policies or procedures that are in place regarding end of life care.

Supporting homes• As there was a delay in commencing training, each home was offered the opportunity for any support from the project leader and to try and form a relationship with the carers in the home. Four homes took up this opportunity: • Home No 2. To discuss difficulties with advance care planning.• Home No 3. To discuss care plans.• Home No 6. To spend a day with the staff. Issues around updating care plans at end of life were discussed with the manager.• Home No 9. To spend a day in the home – an opportunity was taken to inform the staff of the project at break times.• It is reinforced at all the training sessions that the hospice is happy to accept referrals for their residents where they need support for end of life care, and that we will be happy to assist in the implementation of the LCP until they are confident to do this.

Staff assessmentStaff have been asked to complete a competency questionnaire prior to commencing the training. This will be followed up at the meeting highlighted above.

East Sussex

Care Home Pilot Educational Programme

12

The Education Model being used to provide the educational input to the 10 Care Homes is designed around 3 workshops. Workshops will be for both HCA’s and RN’s together. Following the workshops, on going support will be provided to help cascade and support implementation of the learning within each home. This does vary slightly between Hospices although reflects similar content and competencies

Workshop 1 : Introduction to EOLC: Philosophy and Principles and Communication at EOL (September 2011)This workshop includes raising awareness of current initiatives in EOLC and concept of holistic care at EOL

The workshop will run within each care home ( some care homes are joining together for a workshop) so a total of 8 workshop will run. Homes can also send staff to other homes sessions to increase the number that can access the workshop.

This workshop covers all 6 Steps of the National EOLC programme 6 step model.

Workshop 2 : Holistic Assessment at EOLC and Symptom Control (October 2011)This workshop includes common symptoms and their management, and team liaison / accessing resources in management of symptoms The workshop will run 4 times, twice in Bexhill and twice in Hastings at St Michael’s Hospice so each care home can choose which venue it would like to sent staff to. This has been done to aid release of staff to attend.

This workshop covers Steps 2,3,4 and 5 of the National EOLC programme 6 step model

Workshop 3 : Advanced Care Planning and Care in the last Days of Life/After Death Care ( November / December 2011)This workshop covers consideration of MCA, use of DNACPR, LCP and bereavement

The workshop will run 4 times, twice in Bexhill and twice in Hastings at St Michael’s Hospice so each care home can choose which venue it would like to sent staff to. This has been done to aid release of staff to attend.

This workshop covers Steps 2,3,4,5 and 6 of the National EOLC programme 6 step model

Educational Model for Care Home Support Pilot

Session1

Session2

Session3

Nursing Home Pilot EOLC Education Programme

Implementation Support

Additional learning / e-learning

Eval

uatio

n

EOLC Clinical support

Syringe Driver Training

EOLC & Dementia

Liverpool Care Pathway 12

Advanced Care Planning

Grief and Loss

Introduction to End of Life Care

Spiritual Care

Hospice Current Educational Programme and Support Sessions available to Care Homes and Clinical Staff

The above model shows how the Care Home programme and it’sadditional support fits within and can be enhanced thought additional more specialised sessions provided from the Hospice ‘s wider educational programme East Sussex

East Sussex

QIPP EOLC Care Home support -Comparison of Baseline ADAs and Last 5* ADAs uptake of EOLC

toolsHospice Uptake of Advanced

Care Planning (ACP)

Recording of Preferred Place of Care (PPC)

DNACPR completed Liverpool Care Pathway (LCP)

  Baseline End of year

Baseline End of year Baseline End of year

Baseline End of year

St Michael's

percentage 34% 68% 30% 61% 27% 67% 7% 26%

St Wilfrids

percentage 68% 38% 76% 98% 27% 69% 8% 6%

Barriers and Resolutions

• Lack of commitment from care home

East Sussex

Poor engagement with GP’s

• Encourage care managers/DNs/RNs in nursing homes to initiate discussions with GPs, with Hospice at Home providing back up• Circulate letter to GP’s early on in project informing them that they will receive follow up call from homes and Project Lead/Medical Director• Ensure Hospice presence at GSF meetings for surgeries linked to the care homes• Training sessions for GPs

Limited impact of training on change in practice

Syringe driver availability and more syringe driver awareness in educational package Empowering care managers to have confidence to assertively ask GPs for medication Liaison with project link for medicines management On-going support necessary to maintain skills Further work needed from ASC to address access to IT for e-Learning Use of alternative and Hospice e-Learning facilities Adapt training materials to easy read style to allow for communication via pictures rather than too much text More objective project assessment tool or process for collecting information needed

Lack of commitment from care home

• Care Home commitment prior to engagement with project, including fines for non-required attendance at booked training sessions.• Deliver tailored training sessions in care homes wherever possible

Inappropriate choice of care home

• Consult with GP’s and Hospice at Home Choose homes asking for training or those with no or minor CQC concerns Focus mainly on nursing homes as DNs have input to residential homes

Proactive Elderly Advance CarE (PEACE) Tool

• Pilot lead Dr Elena Mucci, Consultant Geriatrician, Conquest Hospital

• pilot for 1 year and will finish in September- data available from October/Nov 2012

• To date discharged 19 patients on PEACE in the first 3 months of the pilot. Only received positive comments from relatives who support this process

• Of 19 patients 6 died-all in their NH, the rest are alive and have not had any admissions.

•  • 1. PEACE discussions on the ward: relatives, NH manager, GP, completion

of community DNAR by myself with agreement from GP.• 2. PEACE completion by doctors, copy goes with the patient and copy given

to relatives• 3. H@H visit within a week: review of patient and education.

East Sussex

Useful links for resources and support• Dying Matters website excellent for both professionals for resources and

information for residents / patientshttp://www.dyingmatters.org/

• National EOLC Programme – excellent professional supporthttp://www.endoflifecareforadults.nhs.uk/

• Routes to Success resourceshttp://www.endoflifecareforadults.nhs.uk/tools/core-tools/rtsresourcepage

• Gold Standards Framework (GSF) for Care Homeshttp://www.goldstandardsframework.org.uk/

• Liverpool Care Pathwayhttp://www.mcpcil.org.uk/liverpool-care-pathway/

• Preferred Priorities for Carehttp://www.endoflifecareforadults.nhs.uk/tools/core-tools/preferredprioritiesforcare

East Sussex

End of Life Care e-learning pilot

East Sussex

The PilotWho?• 2 Home Care Providers• Care Home In-Reach TeamWhat?• To trial access to e-learning programmes for social care

providers, • To monitor uptake• To identify challenges and issues• To assess and develop appropriate support tools• Part of joint EOLC workforce development programme

East Sussex

EOLC training

• Free access to e-Learning resources and the People’s Network

• Open to NMDS–SC registered employers• Linked to QCF Levels 2 and 3 Diploma • 150 sessions in four core competencies• 12 open access modules • Short sessions - around 20 minutes long• Learning tailored to individual needs

East Sussex

East Sussex

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Stakeholders

• Social care providers who:– Deal with end of life care frequently– Occasionally deal with end of life care

• Those approaching end of life, their family and friends Managers

• Volunteers, carers and personal assistants

• Clerical and administrative staff

East Sussex

Benefits

• Well trained and motivated staff• Better quality care and outcomes• Equal access and choice • Excellent personalised care • Improved communications with primary care

colleagues• Compliance with CQC regulations – K4• Delivering best practice and quality standards• Competitive edge - become a provider of choice

East Sussex

Key Tasks

• Benchmarking existing skills

• Training needs analysis to tailor training

• Marketing and promotion

• Monitoring take up

• Measuring impact

East Sussex

Some findings from pilot - staff

• Lack of access to IT equipment

• Difficulties with registration

• On-line support not always effective

• Most staff enjoyed the modules they did

• One to one sessions worked better than in a group

• Printed certificates popular

East Sussex

Some findings from pilot - managers• Generally positive response

• Training resource guide quite useful

• Need for support at front end- e.g.:– Baseline assessment– Training needs analysis– Links with business planning

East Sussex

Next steps…

• Project manager recruited

• Identifying support needs

• Defining programme for roll out

East Sussex

Summary

• Improving EOLC has a high profile…– National and local drivers for change – Workforce development plans and resources– A joint East Sussex EOLC project

• Lots of incentives to improve EOLC

• Training and support is available

• A wide range of benefits and rewards for those who engage

East Sussex

Some questions…

• How can we best work together to take forward EOLC workforce development?

• Are there any logistical issues that need to be overcome?

• Would a more detailed session for a larger number of providers be useful?

East Sussex

For more details please contact:

Kay Muir, Programme Lead , End of Life Care, East Sussex PCTs /CCGsBased at: ESDW PCT Headquarters

36-38 Friars WalkLewes, BN7 2PB(Mon- Thurs.)

Email: kay.muir@nhs.netOffice tel.: 01273 485335Mobile: 07500 972 749

Sophie Clark, Older Peoples Strategic Commissioning Manager, ESCC Adult Social CareBased at: Adult Social Care

East Sussex County Council

County Hall

St Anne’s Crescent

Lewes

East Sussex

BN7 1UE

Email sophie.clark@eastsussex.gov.uk

www.eastsussex.gov.uk

Office tel: 01273 335392 Mobile: 078617471942

East Sussex