Developing Care Home Practice

Care Homes: A Good Place to Live – A Good Place to Die

30th September 2010

Jean Hannah FRCGP, Clinical Director, Nursing Homes Medical Practice

Developing Care Home Practice: A Good Place to Live

Most nursing care home residents in Glasgow:• can choose to register with the Nursing Homes

Medical Practice• access wider NHSGGC Care Home Services

Those people working in the NHMP & CHS:• have chosen to specialise in this area of care• are an experienced, dedicated team• prioritise the hopes, aspirations & choices of the

individual• promote multi-disciplinary & multiagency working

Joint Development Care Home Practice

Important because:• individuals and families have chosen a final home

and their providers of care and support• this is the opportunity to get things right• though some live for much less, 50% of those with

the NHMP live > than 3 years • individuals and their aspirations and support needs

are different – and often complex• success is dependent on establishing common goals

& joint working

Care home practice successes

Dedicated:• Speech & Language Therapy• Dietician• Prescribing Support • Care Home Liaison Nurses• Falls Team Specialists• Pain assessment• Palliative care

All help enhance overall support & care

Pain assessment practice

Pain assessment documentation (n= 80 at start of project, n=80 end of project)

47%45%46%

97%

0%

100%100%100%100%100%

0

10

20

30

40

50

60

70

80

Whole personassessment

Assessment of 'totalpain'

Continuous painassessment

Pain assessmenttool in use

Care plan updatedre: pain

No

of P

atie

nts

Start of Project End of Project

Engagement

• New patient registration• Tailor individual contact in response to need• Advance care planning• Families & carers - loss• Encourage thinking ahead: anticipatory

prescribing

• Because of specialism, understand care options in care homes

Comparison of NHMP vs. NHSGGCprevalence across nGMS QOF indicators

A good place to die: priorities

• Last Months - Identification of the last months of life and pro-actively planning care - taking account of patients’ and families’ wishes – and regularly monitoring needs and care provided

• Last days - Providing the best care possible in last days of life – for patients and families

Identification of Palliative Care Needs

Supportive and Palliative Action Register (SPAR)

• Since July 09 – have been piloting this approach in a number of care homes (nursing)

• Purpose - Identify who to be worried about – in palliative care terms – and be proactive in management – Green – no or minimal

change – Amber – moderate signs of

deterioration – Red – rapid or major

deterioration and may be dying

The key is - Identifying

CHANGE

SPEED OF CHANGE

FAILING RATE(irreversible deterioration)

Be proactive - Action– Green – no or minimal change

• continue optimum long term management – monitor monthly– Amber – moderate signs or rate of deterioration

• Discuss with/prepare family• DNA – CPR• Update anticipatory/advance care plan• Out of Hours Handover – electronic Palliative Care Summary• Monitor weekly

– Red – rapid or major deterioration -may be dying • Discuss with/prepare family• DNA – CPR• Update anticipatory/advance care plan• Out of Hours Handover – electronic Palliative Care Summary• Monitor daily • Consider LCP

Best care in the last days of life• Liverpool Care Pathway for

the Dying – Recognising dying– Ensuring resident

receives the care that they need

– Being proactive– Respect– Preparing the family– Working as a team

• Education and training in relation to– Palliative Care Principles– Liverpool Care Pathway for

the Dying– Supportive and Palliative

Action Register – RN Verification of

Expected Death– McKinley T34 syringe

pumps– Communication skills –

sensitive conversations at the end of life

A natural and dignified death

Challenges

• Staff training and turnover• Inclusion• Recognition of change and failing rate• When to start the LCP• If possible, provide care in care home• Accessing medication & syringe drivers• Finding out what people think and how we

can improve• Supporting carers in the longer term

Harness mutual desire to give the best care - collaboration, co-ordination and respect

Care Home Managers and staff

Care Homes Liaison Nurses Nursing Homes Medical Practice

General Practitioners

Macmillan Primary Care GP and Nurse Facilitators

Palliative Care Practice Development Facilitators

Marie Curie Hospice

Prince and Princess of Wales Hospice

Project Manager: Palliative Care Non Malignant Conditions

Working together

Pharmacy Teams Out of Hours Services

Voluntary, Social Work, Care Commission and Government Agencies