Living Well In Communities

Living and Dying Well in Care Homes – meeting with the Care Inspectorate

Published on 10 September 2019 by Living Well In CommunitiesLeave a comment

On Monday 12 August 2019, we were joined at our offices in Edinburgh by members of the Care Inspectorate’s internal palliative and end of life care group. The purpose of the session was to explore how the Living Well in Communities (LWiC) Team could work with the Care Inspectorate to improve palliative and end of life care for people living in a care home.

Why focus on a Living and Dying Well in Care Homes Collaborative?

There are 36000 people living in care homes across Scotland. In 2017 there were 11300 deaths of Care Home Residents. Ensuring that we get this care right for these people is important. (Data from the Scottish Care Home Census, available on the Information Services Division (ISD) website).

Between March 2017 and March 2019 LWiC delivered a programme of work in support of commitment 1 of the Scottish Government’s Strategic Framework for Action on Palliative and End of Life Care. This work highlighted how we could improve palliative and end of life care for residents, their families and people working in care homes.

For example, there was work taken forward by Riverside Care Home in Glasgow which saw the home using the SPAR tool to identify residents with palliative or end of life needs. This led to an increase in the residents with a jointly agreed care plan in place. These care plans help ensure that the wishes and needs of residents are met. From work elsewhere in Scotland we know there is a link between care plans that are shared using the Key Information Summary and being more likely to die outside of hospital. This is explored further in this article. We know that many people want to receive their care at home and this suggests that care planning is helping people have a better experience at end of life.

We would like to spread the learning from this work across Scotland so that other areas are able to benefit from the learning from this work. We think that an improvement collaborative would be an effective way of spreading improvement at scale across a range of areas. However to ensure that the collaborative would be successful we need to develop the content of the collaborative and make sure that there is an appetite for this approach.

To do this we need to engage with other national organisations, health and social care partnerships, care home staff, residents and their families and friends to establish how best to progress this work. We have identified that we must work in partnership with the Care Inspectorate. Hence why we held this meeting on the 12 August.

What did we talk about?

We had great conversations with our colleagues from the Care Inspectorate to share what have been doing so far, reflect on what we had heard and to discuss the scope of the collaborative. A particular issue that became apparent is our differing use of language and terminology, and we will certainly need to build a common understanding of this.

Everyone was really engaged in the session and we came away with some incredibly useful pointers and feedback. Most importantly we started to build some good relationships that will help us move forward with this work in collaboration.

Going forward

We are looking at how we can continue to work together so that we can harness everyone’s expertise. We also need to think about how we can work with care home providers, residents, their families and staff working in care homes.

Undoubtedly we have a lot more work ahead of us over the next year to engage, scope and develop our approach together with the Care Inspectorate.

Our next step is to hold a workshop with a small group of mostly national stakeholders to help us plan the next steps for this work. We aim to continue our conversations to explore how a collaborative, focused on palliative and end of life care in care homes, could make a positive difference to residents, their families and the staff who are delivering their care and support.

If you are interested in discussing this work, have any examples you would like to share, or would like to be kept updated, then please contact: hcis.livingwell@nhs.net.

Please visit our website for further information https://ihub.scot/living-and-dying-well-in-care-homes/

Frailty, palliative care and me

Published on 15 July 201925 October 2019 by Living Well In CommunitiesLeave a comment

by Tim Warren, Policy Lead for Palliative and End of Life Care, Scottish Government

Tim's mum My mum lives eight hours away, within earshot of Glastonbury (if only her hearing was a little better). Her frailty is a pressing reality. All of the issues which press in at work – frail older people, most with a host of health issues, increasingly lacking capacity, exhausted family carers, stretched paid carers, the role of GPs, district nurses; it all feels very personal.

As the policy lead for palliative and end of life care at the Scottish Government, I frequently have to answer questions about what I do. I usually begin with how ignorant I was when I took on this role, when I mistakenly thought palliative care was basically about hospices and cancer. Of course, I now appreciate that the lion’s share of palliative care is about supporting frail older people like my mum.

When does care become palliative?

So, good care, provided to people at any stage of their care pathway, becomes palliative with hindsight when the person dies. Specialist palliative care, provided in any setting is clearly ‘palliative’. From this perspective, good care, provided in care homes, or by informal carers, supported by district nurses and GPs, and encompassing the spiritual, social and psycho-emotional and the physical, is also ‘palliative care’.

The strategic framework for action on palliative and end of life care (SFA) starts with support for identifying people who stand to benefit from a holistic palliative approach, highlights the importance of conversations with those people (and those who care about and for them), and then aims to provide coordinated care across all settings.

So, who might benefit from a palliative approach?

At what point does support for people with long term conditions become early palliative care? I have come to think about this in two ways. Firstly, thanks to Kirsty Boyd, consultant in palliative care at Royal Infirmary of Edinburgh, I possess the mental metaphor of “umbrella conversations” – conversations to be carried on, not just when it’s raining, but when it might rain. Such conversations might be initiated with a question like, “If you were to get more unwell, what would it be important for us to know about”. Not having these sorts of conversations early, and recording them in a sharable way, can rob people of care and dignity at the end of life. And, although the National Digital Service will in due course enable such information sharing, at the moment the only available mechanism for reliable sharing across settings is the Key Information Summary.

Secondly, another way of looking at who might benefit is by employing “20:20 hindsight”, and reviewing the profiles and care pathways of those who have died over the most recent available year. In 2017 almost 58,000 people died. Around 16,000 of those died suddenly. Of the remainder around 20,000 died with dementia. This gives an additional significance to having those conversations early.

Why early conversations matter

As a policy team we get to see the letters people send to ministers about the care their loved ones receive. One haunts me. It recounts the last months of the writer’s father’s life, in which he experienced increasing frailty, repeated hospital admissions and disjointed care (along with some examples of kind, warm and compassionate staff). He underwent several operations, repeated burst stoma-bags, unmanaged pain and broken promises of ‘fast-tracked care’. The family said it had seemed like a dreadful rollercoaster, which could have been prevented had they just had a realistic conversation about his likely trajectory, and what mattered to him.

Although not all care pathways are like those of this man, all of those who died expectedly should have benefited from conversations about what mattered to them. Paul Baughan, a GP and the Healthcare Improvement Scotland clinical lead for palliative care, led the development of a new palliative care Directed Enhanced Service, to provide some financial support for identifying those who may be moving towards death. (We worked together on the diagram below). It aims to increase the proportion of those with a KIS at the end of life, but especially people with frailty, who have more often been overlooked.

des — Diagram of the Directed Enhanced Service

And it is brilliant to see a focus on ensuring that people in care homes get to benefit from this approach; the work in Edinburgh and Glasgow comes to mind. There is lots still to do, but the support of colleagues in primary care in doing this, and supporting them to do so feels like a key element in making sure that everyone gets the palliative care they need by 2021.

Introducing our Living and Dying Well with Frailty Collaborative

Published on 14 May 201925 October 2019 by Living Well In CommunitiesLeave a comment

20190425 collaborative application tweet v0 1_static

Thomas Monaghan, our Portfolio Lead, discusses our Living and Dying Well with Frailty Collaborative

People in Scotland are living longer than ever before, which is to be celebrated. This means that we all get to spend more time with our loved ones. However, people are not just living longer: they are living longer with more complex health needs and conditions, such as frailty. While we welcome spending more time with our loved ones, we also recognise that it can increase pressure on families, on carers and on our health and social care services to support people to have the best possible quality of life.

Improving care for people with frailty

Supporting people with frailty to have the best possible quality of life is becoming increasingly difficult, as there are growing numbers of older people in Scotland who need support: there will be 25% more people age 65 or over by 2029, and almost 80% more people age 75 or over by 2041.

If we want every older person in Scotland to have the best possible quality of life, then we need to start changing how we support people with frailty to live well in their community.

Our support

At Healthcare Improvement Scotland we want to help health and social care services to make changes so more people with frailty can have a better quality of life in their community. This will help to avoid crises that can lead to poor outcomes and increase pressure on families, carers and health and social care services.

We can do this by helping health and social care services to use evidence and quality improvement methods to:

find people who are becoming frail before they reach crisis point
have anticipatory care planning conversations with people with frailty to understand their wishes for future care, and
work with a range of health, social care, third sector, independent sector and housing providers in local areas to support people with frailty to achieve what they want for their future.

Our Living and Dying Well with Frailty Collaborative

If you want to work with us to help people with frailty to have a better quality of life and reduce pressures on individuals and services, then get in touch. We can talk about how you could be part of our Living and Dying Well in Communities improvement collaborative.

To find out more, get in touch by emailing us at hcis.livingwell@nhs.net, calling us on 0131 314 1232 or tweeting us @LWiC_QI.

Looking forward to hearing from you!

Neighbourhood Care Across Scotland – What Next?

Published on 19 April 201910 May 2019 by Living Well In CommunitiesLeave a comment

Neighbourhood Care Across Scotland – What Next?

On 20^th March the Living Well in Communities team held a national event in Glasgow to mark the end of the first phase of the Neighbourhood Care Programme. It was an opportunity for those involved in the ihub’s national programme of work to come together with other regions in Scotland (and the rest of the UK) that are developing and testing similar models of care. 91 people attended and the roles and organisations present on the day are represented in the two word clouds below.

What is your job role? (n=68)

Word cloud 1

On reflection, an opportunity for improvement would be to facilitate the attendance of more of those directly involved in a care giving role.

What organisation are you representing today? (n=72)

Word cloud 2

There was really good representation from a variety of organisations from all over the U.K. An opportunity for improvement would be to have more representatives from third sector and trade union organisations.

It was particularly interesting to learn that those attending had varied knowledge and experience of Neighbourhood Care in their own areas, with just over half of attendees reporting that Neighbourhood Care teams were currently operating in their place of work.

Are there Neighbourhood Care teams currently operating in your organisation? (n=35)

Poll 1

This poll was over lunch time and responses were lower than other polls.

The aims of the day were:

Meet, network, share and learn from each other and leave with an improved awareness of models of Neighbourhood Care and similar activity being tested throughout Scotland
Consider how the learning and challenges in adopting models of Neighbourhood Care can inform the design and working of integrated health and social care teams of the future
Consider the implications for future local / national policy

The full agenda can be found here, and the slides that were used on the day can be downloaded from the Neighbourhood Care Knowledge Hub (Khub) website. You will have to become a member of the Khub website first before following this link and downloading these, but we’d encourage you to join, as we hope that this website will become a platform for those from different health and social care backgrounds to network, chat and also share resources, experience and data. Just ‘request to join’ online by following the link above, ‘sign up’ and searching for Neighbourhood Care on the Knowledge Hub, but if you have any difficulty, please contact the team on hcis.People-LedCare@nhs.net.

The audience participation tool, ‘Slido’ was used for delegates to ask questions throughout the day and to engage with each other. It was new for the majority, but most people mentioned that they liked using it in their evaluation forms, so we look forward to using it more at future events.

Have you used Slido/similar before? (n=59)

Poll 2

In the first part of morning, we heard from a variety of presenters in national roles: Chris Bruce, National Advisor, Neighbourhood Care Programme, Maria McIlgorm, Professional Advisor, CNOD, Scottish Government, Joanna MacDonald, Chief Officer, Argyll & Bute HSCP, and Jane Johnstone, Professional Social Work Adviser, Scottish Government.

They discussed what Neighbourhood Care meant in Scottish/integrated care context. We then heard from a mixture of sites from all over Scotland that are implementing models of Neighbourhood Care in their Health and Social Care Partnerships (HSCPs). This included South Lanarkshire HSCP, Greater Glasgow & Clyde HSCP, Angus HSCP, Cornerstone, Aberdeen City HSCP, Western Isles HSCP, Clackmannanshire & Stirling HSCP, NHS Highland and Argyll & Bute HSCP.

Generally it was acknowledge that there is definite merit in working in this way both for staff and people that receive care, but there are common challenges too.

After lunch, delegates had the opportunity to discuss the top five voted questions in the room and then the ‘barriers’ and ‘enablers’ to delivering models of neighbourhood care in different settings (with a particular focus on ‘what are the current/required solutions?’) as part of a world café session.

The engagement in these conversations was really worthwhile and produced a lot of valuable intelligence that will help guide the future national direction of this programme of work.

As there wasn’t enough time on the day to answer all the pertinent questions posted on Slido, the LWiC team decided to pose these questions to the most appropriate individuals/teams and collate the responses. Thank you to all who have provided the questions and the answers. The response document can be found by following this link.

The world café session provided information that was particularly useful. The full transcription of the flipchart notes from the twelve individual tables is here, but the world cloud below that has been generated from combining all discussions highlights the key themes really well.

Word cloud 3

Within the Healthcare Improvement Scotland’s Improvement Hub (ihub), the Neighbourhood Care programme will move from the Living Well in Communities (LWiC) team to the Person-Led Care team from April 2019 as it enters a second phase. Chris Sutton, Portfolio Lead for the Person-Led Care team, introduced herself to the room on the day and will use the outputs from these valuable discussions to inform the future actions needed to support the delivery of the Neighbourhood Care Programme going forward. For any further information or to find out how you and your team can engage, please contact the Person Led Team on: hcis.People-LedCare@nhs.net.

Fiona McQueen, Chief Nurse, Scottish Government rounded off the day with her reflections. Fiona discussed the great impact stories that were shared earlier in the day and stressed that working together in an integrated manner is the only way to provide truly person-centred and holistic care.

‘We still have a long way to go, but it’s a very worth-while journey’

Thank you to everyone who attended. Here are a few short ‘Vlogs’ that captured your general experience and learning on the day.

Future general enquiries/information requests should be directed to hcis.People-LedCare@nhs.net

Thought bubble

Thought by Nociconist from the Noun Project

ACP in Care Homes

Published on 9 April 201919 August 2019 by Living Well In CommunitiesLeave a comment

Dr Andrew Mackay, ACP GP Advisor to the Edinburgh Health and Social Care Partnership ACP team.

“Definitely thinking back to those days where people were not thinking about these kinds of things. We were not always doing the right things for the residents, the appropriate things.” Care home staff member.

For the last year I have been working as part of a team to embed Anticipatory Care Planning (ACP) in 20 care homes across Edinburgh. Like the staff member above, many people involved in looking after care home residents appreciate that admission to hospital is not always what the resident wants when they are acutely ill. Some just really don`t want to go to hospital at all and others feel that their quality of life is now such that if they were seriously ill they would prefer to be kept in the home they know with treatment being provided there, even if that meant they couldn`t get all the possible treatments for their condition. We were keen to see whether training the care home staff in how to discuss ACP`s with their residents and how to use the completed ACPs in an emergency would reduce the number of avoidable admissions to hospital.

The care home staff immediately got it. They all want to provide high quality person centered care and they hate to see residents ending up in hospital when it is unlikely to help them. When this did happen many staff felt as if they had somehow failed their residents. What is more, many of them were already having conversations about the future, but they found them difficult at times and didn’t know how to use this information in the best way. The GPs were also delighted to get some help with gathering the information they needed to create a high quality ACP. They all wanted to do their best but had been overwhelmed with the time needed to do it properly. The idea that the person having a ‘good conversation’ with residents or relatives with someone that knew them well seemed obvious to everyone. In most situations that person was a member of the care staff.

The staff were really positive about the tools we showed them that together comprise the ‘7 Steps to ACP for Care Homes’. They were brief, simple and included lots of explanation. Although anxieties still remained. Much of the time people arrive in care homes from hospital, where they have been pretty unwell. They and their relatives are going through a huge readjustment. Trying to figure out the present is a challenge and thinking about how to direct future care seems impossible to some when they are new to the home. For some, even when the initial dust has settled conversations about their or their relative`s plans for the future are still not easy. I have been having these conversations with care home residents and their relatives for years and sometimes I still don`t get it right. Our trainer was able to work with staff to help with this. It can be really useful to have a few phrases you are comfortable with to help introduce the subject and to be able to back that up with some written explanation.

Getting the GPs on board was also pretty straightforward. They saw immediately the logic of the system we offered and we were also able to help train some of their admin staff to take on the basic data entry. As one practice manager said to us: “If it is an admin task that needs to be done, please don’t ask the GPs to do it. Our team does it much better!”.

So, the questionnaires were completed and passed to the GP, the ACPs were entered as special notes in the residents Key Information Summary (KIS), that form was printed and returned to the care home. The next big challenge was using the ACPs in an emergency. Whenever a resident becomes suddenly acutely unwell it is scary for those looking after them. Particularly when we started, some staff would feel better calling for an ambulance. Through work with our trainer they became confident in using the ACP to guide their actions and to help guide the actions of out-of-hours doctors and ambulance crews. It was really useful for the staff that we helped them complete reflective logs of each of the acute events and then met with them to discuss all the episodes every 6-7 weeks. It was a happy coincidence that many nurses needed to complete reflective logs for revalidation so were keen to do it with our help.

phase 3 care home rectangle clip with logos 0 1 (2)

Care home staff are busy people and I often worried that they would struggle with what was, in some ways, extra work. So it was wonderful at our recent end of program celebration to see so much enthusiasm from the staff about ACP. Person after person thought that this process had helped them deliver far better care for their residents. It was heartening to be able to share with them that there had been a 32% reduction in potentially avoidable admissions to hospital from their homes over the first ten months of the programme. However, I was even more pleased to see just how positive they were. It gave me a lot of hope for the future. Talking of the future, I now really hope we can sustain them. Some care homes have up to 30% turnover of staff so the effect of other programs has faded over a few years. We have tried to address this by recruiting several `ACP Champions` in each home and training them to carry the message onwards. We’re also developing an implementation package to support the ‘7 steps’ toolkit with training material, videos, leaflets etc.

“…ACP is a very good programme for us to do our job as expected from us” (Care home deputy manager).

“The ACP pathway helped. It helped tremendously. I don’t think we would get anywhere without using it. Explaining each stage more fully to the resident, and he understood why we were asking. He said it was a relief and a comfort to talk about it.” (Care home champion)

“I find that staff are initially shocked that someone might not want to go into hospital for treatment and might want to be kept comfortable in the care home. It’s been really important in providing us with confidence to speak about what people’s wishes are if they become really unwell.” (Care home champion)

“If you want to enhance your practice you have to buy-in to this process. We are supporting person-centred care and this supports us from the very beginning. They’re telling us what they want and we are here to facilitate that.” (Care home manager).

Long may it continue and let`s spread the word.

Written on behalf of the Edinburgh Health and Social Care Partnership’s Long Term Conditions Programme ACP team.

For more information and resources relating to ACP visit the ACP toolkit.

“ACP is not for me!”

Published on 19 March 2019 by Living Well In CommunitiesLeave a comment

paul baughan

“I don’t have time to do an ACP.”
“That document is too big.”
“GPs have enough work without this.”
“Someone else should be doing it.”

These are all comments which I have heard my GP colleagues say when the topic of Anticipatory Care Planning comes up. And if I’m honest, there have been occasions when similar thoughts have gone through my head. But Anticipatory Care Planning is so much more than any document or the needs of a particular professional group, and I have come to realise that it is a fundamental component of our work in general practice.

Some of the most rewarding consultations I have had, started with an exploration of ‘what matters most‘ to someone. Recognition of such priorities enables the most effective use to be made of limited consultation time. And often I am surprised that the most important aspect of someone’s care is not what I thought it was going to be.

Take for instance my patient John, who has significant heart disease and was frustrated about the poor control of his blood pressure. I could see John’s irritation and was determined to find a new combination of drugs that would work better than the last. Each switch to a different medication required more blood tests and close monitoring, and unfortunately many of these new drugs made John feel dizzy and light-headed.

One day John told me that his greatest pleasure in life was spending time with his grandchildren, and until recently he would drive them to and from school each day. Side effects from his medication were preventing this, which in turn caused John to feel stressed. Only by understanding his priorities were we able to make progress. He was willing to accept the risk of a slightly higher blood pressure if it meant he could safely drive his grandchildren and ‘feel useful’.

So, after discussion we stopped his medication, put the BP monitor to the side, and instead explored other aspects of his future care which were important to him. His Key Information Summary was updated to include his thoughts about cardiopulmonary resuscitation and he set about appointing a welfare power of attorney. John was able to start driving again and his levels of frustration reduced, as did his blood pressure!

ACP desktop Anticipatory Care Planning is not a one-off event. It is a process that starts with a conversation and which can develop and evolve over time. The beauty of general practice is that we have opportunities to initiate that conversation and contribute to the development of an ACP over weeks, months and sometimes years.

Professionals working in other parts of health or social care can also make a big contribution to ACP. Tools such as My ACP can support this process, and stimulate helpful discussions within families. There is still a challenge translating information from hospital clinic letters and My ACP onto the KIS. I welcome recent progress with the new national digital platform, which in time will allow a wider group of people to contribute to an electronic shared ACP.

So, ACP is not just for me. It is for all professional groups working across health and social care, and most importantly it is for the person, their family and carers.

Paul Baughan, GP, Dollar Health Centre, Clackmannanshire

For more information and resources relating to ACP visit the ACP toolkit.

What works in care co-ordination in palliative and end of life care

Published on 19 March 201914 March 2019 by Living Well In CommunitiesLeave a comment

We have recently published a resource that reviews the evidence on continuity and care coordination in palliative and end of life care. This blog post gives an overview of the document and its features.

Why focus on care coordination?

Good care co-ordination can help to improve people’s quality of life, right up to the end of life.

The Living Well in Communities team has been working with test sites in Dundee, East Ayrshire, Fife, Glasgow City, and Renfrewshire Health and Social Care Partnerships to deliver Commitment 1 from the Scottish Government’s Strategic Framework for Action on Palliative and End of Life Care:

“We will support Healthcare Improvement Scotland in providing Health and Social Care Partnerships with expertise in testing and implementing improvements to identify those who can benefit from palliative and end of life care and in the co-ordination of their care.”

This work is coming to a close in March 2019.

Exploring the evidence on different approaches

Drawing on the priority practices outlined in the World Health Organization practice brief on continuity and co-ordination of care, we identified six key approaches to continuity and care co-ordination in palliative and end of life care:

Early integrated palliative care
Collaborative planning of care and shared decision making
Case management for people with palliative and end of life care needs
Intermediate palliative care at home
Technology to support continuity and care coordination
Building workforce capacity

Working with the Evidence and Evaluation for Improvement Team, we summarised the available systematic-review level evidence on these approaches.

Presenting the evidence visually

As with our Living Well in Communities with Frailty evidence review, we produced visual summaries for each of the approaches. These provide key information on the different approaches to care coordination, and an introduction to the more detailed evidence summaries. The visual summaries include

a brief description of each approach,
the rationale behind them,
the potential benefits,
enablers,
brief commentary on the quality of the evidence, and
links to further reading and examples of local good practice.

Visual summary — Early integrated palliative care visual summary

Case mgmt summary — Case management evidence summary

We hope that this document will provide a useful overview of the systematic review-level evidence on key approaches to care co-ordination in palliative and end of life care, and highlight the potential benefits of these approaches.

You can access the review, Continuity and Co-ordination in Palliative and End of Life Care: evidence for what works by clicking on the document image below:

Care Co-ordination Short Stories

Published on 21 December 20183 January 2019 by Living Well In CommunitiesLeave a comment

A number of Palliative Care professionals who attended our Palliative and End of Life Care Delivery Group on 8th November kindly shared some insights into how to better understand care co-ordination. You can find out more by looking at the slides from the day here.

Sandra Campbell (National Clinical Lead) presented on the importance of timely, sensitive conversations. Conversations should begin at the point of need by whoever is identifying the need / transition. The Palliative Care Identification Tools Comparator can be used to allow people to make more informed choices about their care and treatments when they have an irreversible illness. Significant conversations happen at the right time, in the right place with the right person.
Deans Buchanan (Consultant in Palliative Medicine, Lead Clinician) spoke about Health Transitions in Human Stories. Stories are very important to how we understand and communicate with one another. Most patients’ stories will have been interrupted by their illness and this can affect their response to treatment. The A, B, C, and D approach of dignity conserving care (Attitude, Behaviour, Compassion and Dialogue) is one method being tested to remind practitioners about the importance of caring for their patient.

Heather Edwards (Dementia Consultant, Care Inspectorate) gave a good overview of Bereavement. Heather highlighted the importance of preparation for death and the value of the care home staff in supporting families. Bereavement can cause an emotional toll on the staff as well as families but it’s important that we also support them as they are also grieving having developed relationships with the residents and their families.

Lynne Carmichael (Respite & Response Team Manager, Ayrshire Hospice) presented on carers and the Carers Support Needs Assessment Tool (CSNAT). One of the first barriers is many carers do not recognise themselves as a carer and often put their own needs to the side to care for a loved one. The CSNAT tool helps provide support for family members and carers of those with a life limiting condition.

lynne

Jo Hockley (RN PhD, Usher Institute, University of Edinburgh) presented on Care Co-ordination and Care Homes. As the population of over 80’s increases, they are becoming increasingly frail and more dependent, resulting in increased pressures on healthcare professionals supporting care homes. The main issues are:

– Lack of recognising the dying
– Lack of healthcare support to palliative care
– Lack of support staff

More work will need to be done around linking care homes into the system. This will hopefully be aided by a similar study to the Teaching Nursing Home pilot whereby the public/professional perception of care homes change, encouraging a career pathway in care homes for health and social care professionals, to help increase the workforce and establish more community engagement in care of frail older people.

Richard Meade (Head of Policy and Public Affairs, Marie Curie Scotland) offered an insight in Looking Beyond 2021 and thinking about the future. As the population is living longer, more people will be diagnosed with multi-morbidities, including dementia, frailty and cancer, and will therefore require increased palliative care. This in turn will increase the pressures on every care setting, the workforce, resources and the way we deliver care, and we must act now.

Anne Finnucane (Research Lead, Marie Curie Hospice Edinburgh) presented on the Key anne Information Summary (KIS) and a recent study undertaken on those who died with an advanced progressive condition in 2017 with a KIS in place. A KIS is a shared electronic clinical summary used to guide urgent care in the community and emergency hospital admission. It helps to communicate key elements and preferences from the person’s Anticipatory Care Plan (ACP) to help with future care needs.

Ali Guthrie (Learning & Development Advisor) discussed Personal Outcomes: towards a Shared Understanding. A Personal outcomes approach is focusing on what is important to people in their lives. They often relate to maintaining or improving wellbeing and feature in the National Health and Wellbeing Outcomes in the new Health and Social Care Standards.

For further information, please contact a member of our team at hcis.livingwell@nhs.net

Follow us on Twitter:@LWIC_QI, @turnersara99 @paulbaughan, @sandracampbellc65402031

Understanding the success factors in Care Co-ordination

Published on 21 December 201818 January 2019 by Living Well In CommunitiesLeave a comment

Our local Palliative & End of Life Care (PEOLC) test partners came together on 8^th November 2018 to exchange knowledge and understand the success factors for care co-ordination. The morning session provided an opportunity for the five health and social care partnership test sites to share the improvements in care co-ordination that they have been taking forward locally. Each site has approached this challenge in a different way, working with different population groups, in different settings and with a variety of different interventions. However, the objective to improve the co-ordination of palliative and end of life care remains consistent across each area, with promising early outcomes now emerging from this work.

Test Sites

We have five main test sites involved in identifying those who would benefit from a palliative care approach:

Dundee
Fife
East Ayrshire
Renfrewshire
Glasgow

Experts from Marie Curie, Ayrshire Hospice, Care Inspectorate, University of Edinburgh and The Scottish Social Services Council (SSSC) were on hand to provide short stories and share current thinking to help with our understanding of Care co-ordination.

whos here today

The afternoon was a World Café format – a world café is a simple, effective and flexible format for hosting large group dialogue. It provides an opportunity to exchange and share knowledge. Test site leads led the table discussion and answer any questions in relation to their site and Care Co-ordination.

world caFE

Evaluation Comments

“This was a great day, what an opportunity to have a day with space to network, think and create for the future”

“Everyone’s opinion counted”

“Open environment to discuss palliative care with professionals in different areas”

“Rich conversations”

“Great opportunities to learn what is happening and being developed across Scotland and a chance to network and share ideas”

“Really valuable sharing and networking; very much stimulated ideas for us to test”

“Group discussions, listening to different ideas and realising that we are all wishing and working for the same outcome”

Key to good care co-ordination in PEOLC

Attendees tested out Mentimeter, a fun and interactive tool for presentations, to create a word cloud describing the key to good care co-ordination:

mentimeter

Closing comments from Paul and Sandra

Paul Baughan and Sandra Campbell (National Clinical Leads) provided some words from the day:

“There are many different components to good co-ordination of care at the end of life. This gathering allowed those testing new ways of working to meet and share their progress with like-minded individuals and experts in the field of palliative care. This knowledge exchange is mutually beneficial and has provided a renewed impetus for our five test sites to make progress with their change ideas.”

“It was an excellent day, with really engaging conversations and sharing of best practice… and great to hear about such good work across the country.”

Next Steps

Paul and Sandra are currently working on an evidence bundle for Care Co-ordination alongside the Evidence and Evaluation for Improvement Team (EEvIT), the first draft will be ready at the end of January. The evidence bundle will inform which interventions help people to die in their preferred place of death, which interventions help to decrease the percentage of hospital deaths, and the interventions that increase the percentage of deaths at home and in hospices.

For further information, please contact a member of our team at hcis.livingwell@nhs.net

Follow us on Twitter:@LWIC_QI, @turnersara99, @paulbaughan, @sandracampbellc65402031

Neighbourhood Care Steering Group

Published on 3 December 20183 December 2018 by Living Well In CommunitiesLeave a comment

Our recent Neighbourhood Care Steering Group took place on 21^st November at The Studio, Glasgow. This session focused on measurement and provided an opportunity for our test sites to update each other on their progress and any challenges encountered since our last meeting.

NC pic 1

Care Experience Measurement

Our public partners, recently attended training on Care Experience, delivered by the Person Centred Care team in the hope that each public partner will link up with an active test site and assist them in capturing care experience in their local area. A further training session will happen in the New Year and those from the HSCP pilot sites are welcome to attend.

The group was shown an example of a “Care Experience Map” and asked if this would be helpful in developing one for each active site, with 1 or 2 patients being interviewed (Aberdeen City, Scottish Borders and NHS Highland). The Care Experience Maps would be used to capture the current care received from Neighbourhood Care teams, and could highlight opportunities for quality improvement work for local teams.

Knowledge Hub

The Steering Group have previously expressed that they would like to have a platform to share information around Neighbourhood Care in between the Steering Group meetings. As a result, the Living Well in Communities (LWIC) team have created a Knowledge Hub site. It provides a chance for those interested in testing similar models to network and share ideas and will be open to all roles in all areas.

The LWiC team had brain stormed these folders and suggested some sub folders, as well as uploading a few examples of documents that sites may find useful to share. Everyone was invited to “test” out the page and offer suggestions that would help improve the page before it gets shared more widely with local test site teams. Sites were asked to feedback their suggestions to the LWiC team and nominate a member of their team as ‘administrator’ who will be responsible for updating and uploading documents to their site’s folder.

Measurement

A small NC Measurement sub-group formed on the back of the last Steering Group and met to develop a set of common measures for all sites based on the 7 common themes of measurement:

Re-ablement
Customer satisfaction/experience
Staff satisfaction
Procedures
Workforce
Professional Autonomy
Community impact

The steering group was briefed on the 10 suggested measures and asked if they would be both useful and easy for Neighbourhood Care teams to measure. Some of the measures included:

“The percentage of time spent by nurses and carers that:

is directly person facing time or Involves person centred activities”

“The average number of team/staff members visiting each person per day/per week”

“The percentage of attendees who join the regular team meetings that discuss and plan care/case load”

“Number of steps in a process that require approval to be sought [before a neighbourhood care team/control group and with a neighbourhood care team”? I.e. “How many barriers removed?”

All suggestions were useful and would be of particular interest to team members, but some may prove challenging to capture. Neighbourhood Care Test Sites will now test ways to capture some of these measures and have been asked to help define them more precisely.

For any further information on any of the above, please feel free to contact one of the team:

hcis.livingwell@nhs.net