The Bromhead Care Home
Service: Phases 1 & 2
Gill Garden
United Lincolnshire Hospitals NHS Trust
[email protected]
Evidence
Care Homes:
• Many residents have dementia
• Life expectancy is poor
People with advanced dementia:
• Have poor outcomes from hospital admission
• Are more likely to have interventions
• Are less likely to be offered palliative care
• Advance care planning has been shown to reduce
hospital admissions without increasing mortality
Royal College of Psychiatrists (2005) Who Cares Wins
Molloy et al. (2000) JAMA, 283: 1437-1444
Caplan et al. (2006) Age and Ageing, 35: 581-585
3/3/2015
Phase 1: 2011
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Funding: The Bromhead Medical Charity
Staff: 2 RGNs + consultant support (unfunded)
Location: 7 care homes in Boston, Lincolnshire
Patients: residents with dementia
Service
– Training on delirium, eating, drinking & dysphagia
– GSF assessment (most frail prioritised)
– Care planning
Individual Resident Assessment
Presence of dementia/suspected dementia
• Nutrition: MUST
• Activities of Daily Living: Barthel
• Waterlow
• Cognitive assessment
3/3/2015
Implementation of Advance Care Plans
• Most frail & dependent
prioritised
• Mental Capacity
Assessment
• Care planning:
– families approached by care
home staff
– undertaken on best interests
basis
– meetings involve:
• Staff, family/close friends /POA
• History, current health, prognosis
& end of life care discussed
• IMCA for residents without NOK
• Care Plans sent to care home,
GP & filed in medical notes
• DNACPR forms completed by
care home liaison nurses &
endorsed by GP
• Frequent support in the
practicalities of using the ACP
• Involvement of palliative care
services when time
appropriate
3/3/2015
Phase 1: Outcomes
Training
Admissions from Care Homes
250
200
150
Admissions
100
50
0
3/3/2015
Carer Feedbacker
SatisfactionCarer
“Excellent service”
“My mum had made a
living will & it was
something she always
talked about with her
family, this process has
given me the confidence to
know my mum’s “voice” will
be heard even though she
can no longer communicate
effectively. As a family we
also feel we have been
given the opportunity to be
“heard” for the first time”
“Found the nurse to be very
helpful in her explanations of all
questions I asked. All was put in a
very easy to understand way. I
think this idea of advanced
planning is very good, & allows
relatives input into their family
members care instead of being
made to feel it is nothing to do
with you”
“I met with the nurse & although I understood
what an advanced care plan was I found it
comforting to discuss the details with a nurse
who showed so much empathy &
understanding. If I have any queries in the
future I wouldn’t hesitate to contact the nurse
knowing that she would find time to talk to me
without judging”
Phase 2: What we are doing now
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Funding: The Bromhead Medical Charity
Staff: (3.25WTE): 1 medic, 1 OT, 1 physio, 2 nurses
Patients: residents in 24 Lincoln care homes
Service Model
– Care Homes randomised to avoid selection bias
– Step Wedge
– All residents to be offered CGA & ACP
Phase 2: Service Evaluation
• Health Service Utilisation
– Admissions Secondary Care
– Investigations/interventions*
– Primary care intervention*
• Deaths
– Overall number
– Deaths in preferred place of care
• Carer Satisfaction
Comprehensive Geriatric Assessments
Degree of Frailty and GSF Status
70
60
50
40
%
30
20
10
0
none
vulnerable
mild
moderate
severe
GSF +ve
Cognitive Impairment
Average Montreal Cognitive Assessment Score
16
14
12
Bunkers Hill*
10
Neale Court
8
Monson RH
6
Morton Court*
Ruckland Court
4
Hartsholme House
2
0
male
female
Advance & Anticipatory Care Plans
Preferred Place of Care & Place of Death
Relationship of ACP/AnCP v ACP
Declined v No ACP on Place of Death
New Interventions
• Key worker designated for each care home
• Red wallet
– DNACPR
– ACP/AnCP
– Hospital Information Pack
• EPaCCs on Systm1
• EMAS: sticker on care home door alerting EMAS
staff to red wallets/DNACPR/ACP being used
What have we learnt so far..
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ACPs greatly increase chances of dying in PPofC
Implementation more challenging in Residential Homes
Individual care home culture crucial
Response has been overwhelmingly positive
Confounding external factors:
• Care homes:
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Deregistration of nursing beds
Qualified Staff –switch to RMNs
Staff with entrenched attitudes
Support
• EMAS
• GP cover and perspectives
• IT Systems need to be accessible and compatible
Challenges
• Patients transferred from LCH to care homes,
particularly fast track
• Universal use of red wallets and HIP packs
• IT system communication:GPs, hospital, LCHS
What the service should be part of
– Neighbourhood teams/LCHS?
– ULHT?
– St Barnabas?
• Will service be commissioned in some format?
The End
Any Questions?
[email protected]