Connecting Health and social care to Offer Individualised Care at End of Life

Dr Caroline A.W. Dickson, Senior Lecturer in community Nursing, QMU, Edinburgh

Helena Kelly, Lecturer Glasgow Caledonian University

Janice Logan, Lecturer, St Columba’s, Hospice Edinburgh

OverviewTo develop and test an

initial framework of integrated working to

facilitate person-centred care for patients and

families at the end of their life who are being cared for

in their home.

Background• Key national drivers – integration and person-

centredness (NHS Scotland 2013; DH 2014)

• Enabling ‘everyone to live longer and healthier at home, or in a homely setting’ (SG 2008; 2013; DH 2014)

• Integrated ways of working (SG 2013; DH 2014)

• Little research underpinning the role of the care worker or integrated working in this area of practice (Herber and Johnston 2013; Devlin and McIlfatrick 2009)

• Queen’s Nursing Institute: Nursing Creating Connections Project Grants

Methodology

Realist synthesis(Pawson 2008)

Participatoryresearch McCormack &

McCance (2006)

PracticeDevelopment(McCormack et al. 2007)

Stakeholder involvement

Refined by stakeholders

•Steering Group

•Project Group

•Focus groups

•Practice Development Group

Ethical approval sought and granted.

Rapid review of literature drawing on realist synthesis

Aim•'to articulate underlying programme theories and then to interrogate the existing evidence to find out whether these theories are pertinent and productive'

Intention•to uncover theories about interventions - what makes it work (or not) in a given context adopting particular mechanisms of action

Identify the question

Clarify the

purpose of the reviewArticulat

e programme theories

Search for the evidence

Appraise the evidence

Extract the results

Synthesis findings

Consultation &

refinement of

findings

Clarify purpose of reviewIdentify the question:‘ In maintaining person-centred end of life care for patients and their families at home, what aspects of integration work, for whom do they work, in what circumstances and why?’

Sub questions based on the key question above:•What is the nature of Health and Social care Integration?•What are the prerequisites for its use?•What policies drive integrated care at end of life at home?•What is the expected impact of integrated Health and Social Care at end of life care at home?

Policies driving integrated care at EoL at home

• Living and Dying Well (SG 2008)• Routemap to 20 20 Vision (NHS Scotland

2013)• Caring for People in the Last Days and Hours

of Life (NHS Scotland 2014)• Gold Standards Framework

(http://www.goldstandardsframework.org.uk/)• Quality Strategy (SG 2009)

Nature of health and social care integration

• Cooperation-coordination (e.g. MCNs) fully integrated (joint planning and management/ pulled funding and MDTs) (Kodner and Spreeuwenberg 2002; Eyre 2010; Karlsson and Berggren 2011: Gardiner et al 2012)

• Focus on prevention/anticipation and focused SM to ensure minimal risk and unnecessary hospital admission (Bower et al 2010; SG 2013; Beland 2013)

• Working in partnership with patients and families (Nikanen 2002)

• Each member of the team aware of patients needs and others roles and responsibilities (Alsop 2010; DeMiglio and Williams 2012; Gardiner et al 2012)

• Early intervention/effective planning/same day assessment (Bower et al 2010)

• Patient focused/person-centred; Based on a holistic model of care (Ahmed 2011)

• Based on a patient pathway (Robertson 2011)

• An inter-agency approach to care planning• Values based model of care (Payne 2007)

Pre-requisites

Improved patient experience

Expected Impact

Increased job satisfactionDignifie

d careSupport for carers

Support for professionals

Equity

Enabling families and carers

Respectful working relationships

Sharing good practice

Seamless care

Person-centredness

Openness/accessibility

Making every contact count

Effective teamwork

Responsive services

Overcoming professional boundaries

Increased collaboration with GPs

Consistent policies

Easy referral process

Synthesising evidence

• Brainstorming project team

• Brainstorming steering group

• Focus groups– Family carers– Community nurses– Social care workers

Articulate programme theories• A Person- centred approach drives integrated working for

patients at end of life at home.• Workplace and Organisational cultures affect successful

integrated care at end of life.• Working in partnership with patients and families will enable

self-management and improve the patient and family experience of end of life care at home.

• Good case management features effective leadership supported by integrated organisational structures.

• A holistic person-centred model of end of life care will be enhanced by effective collaboration.

Practice Development Group

Testing using Practice Development

• Vision• Prioritising• Action planning• Evaluation• Refinement

(McCormack et al. 2011; Manley et al. 2013)

Shared visionIntegrated person-centred EOL Care at home is……..

Skilled health and social care staff working together, supporting each other to build a relationship with the

‘cared-for person’ and family and/or significant others to provide holistic care where everyone feels valued, has choice and dignity through open communication.

We will work together with ‘cared for persons’ to asses, plan and evaluate care of their choice giving sufficient time to give streamlined, coordinated care with staff

continuity to achieve a dignified death.

Action planning

Identified priority Relationship to modelIdentify social care workers interested/keen to engage with EOL careEnsure skilled staff (education and training)Shadowing opportunities

Organisational structures – robust selection and recruitmentEducation and training  

Integrated team meetings (?monthly)Early interventionEffective care coordinationEffective discharge

Organisational structures – Integrated teams with a shared vision and goalsA culture where everyone feels valuedTeam structures - Identified care coordinator 

Improve communications – systems, team, and care plan?Joint visits and joint communication (inc documentation) 

Organisational structures –A culture where everyone feels valuedBuilding resilience and capacitySupport for everyone involved.

What next?Further refinement

Questions for you – •What are the strengths of this model?•How could it be further refined? https://www.google.com/search?

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References• DEPARTMENT OF HEALTH 2014. The Five Year Forward View. DH London.• GOLD STANDARDS FRAMEWORK http://www.goldstandardsframework.org.uk/ [Accessed 24th April 2015]• HERBER, O. and JOHNSTON, B., 2013. The role of healthcare support workers in providing palliative and end-

of-life care in the community: a systematic literature review. Health and Social Care in the Community. Vol. 21, no. 3, pp. 225-235.

• DEVLIN, M. and MCILFATRICK, S., 2009. The role of the home-care worker in palliative and end-of life care in the community setting: a literature review. International Journal of Palliative Nursing. Vol. 15, no. 11, pp. 526-532.

• MANLEY, K., TITCHEN., A. and MCCORMACK, B., 2013. What Is Practice Development and What Are the Starting Points? In B McCormack, K Manley and A Titchen (2013) Practice Development in Nursing (Vol 2). Wiley-Blackwell Publishing, Oxford. pp: 45-65

• MCCORMACK, B., DEWING, J. and MCCANCE, T., 2011. Developing Person-centred Care: Addressing Contextual Challenges through Practice Development. The Online Journal of Issues in Nursing. Vol. 16, no.2

• NHS SCOTLAND 2014. Guidance: Caring for people in the last days and hours of life. Edinburgh: NHS Scotland• NHS SCOTLAND.,2013. A Route Map to the 2020 Vision for Health and Social Care. Edinburgh: Scottish

Government.• PAWSON. R., 2006. Evidence-based Policy: A Realist Perspective. London: Sage Publications Ltd• SCOTTISH GOVERNMENT., 2008. Living and Dying Well: A national action plan for palliative and end of life

care in Scotland. Edinburgh: Scottish Government.