STEP 3 - CO-ORDINATION OF CARE

STEP 3 - CO-ORDINATION OF CARE

Step 3 - Co-ordination of Care Objectives: Anticipating care Sharing information - the wider MDT Anticipatory medication Out of Hours The Key Worker Portfolios, Step 3 To Do List End of Life Care Policy Evaluations DNAR in advance care planning

Co-Ordination of Care Anticipation - key to effective service provision Effective communication Information gathering Information sharing Ownership, responsibility Clear plans - shared

Remember - Consent Documentation Sharing the plan of care, information Reviewing the plan of care, updating, sharing

Co-ordination of Care “If a patient is likely to live for a matter of weeks, days matter, if the prognosis is likely to be days, hours matter.” End of Life Care Strategy, DH 2008

Co-ordination of Care Co-ordination - may require multiple agencies at different times, e.g. home, hospital, care home, hospice Need to be aware of available services Co-ordination is a major activity Whose responsibility? - Can take away from direct delivery of care Lack of co-ordination = Increased chance of dying in place not of choice

Co-ordination of Care Need to consider at different levels: Within an individual team Between teams Across organisational boundaries

Out of Hours Care

Why is it important? In a seven day week, 75% of the time falls OOH

‘From my own palliative care patients I would hope that I would have them well enough organised in hours that they wouldn’t need to call out of hours.’

Problems perceived by OOH’s Lack of information

Problems perceived by OOH GPs Lack of information on patient OOH Workload, time pressures Unexpected deterioration Lack of skill/knowledge?

“Even in the best service/team things go wrong and you can’t always know what’s going to happen. People deteriorate very suddenly… suddenly they think they can’t do it and it’s a crisis.”

“The easiest thing to do OOH is to send them in – that solves the problem. You don’t have to go back, you know they will be taken care of. I don’t mean to sound cynical about that. You are moving from one patient to the next very quickly in a busy night – these sort of patients need a bit of time.”

‘The main difficulty is… going into a situation cold and trying to judge everyone’s agenda.’

What is best for patients? Effective anticipatory care to reduce the need for OOH calls

Out-of-hours (OOH) issues ideally anticipatory prescribing already in place need to be aware of issues when not in place or unexpected deterioration occurs OOH can also do anticipatory prescribing – may reduce further visits good communication needed OOH, especially with family and district nurse team

Two roads to death

Managing end of life care (how to avoid the difficult road) anticipation co-ordination explanation comfort support

Anticipating symptoms How common are symptoms in terminal phase?

Common symptoms in Terminal Phase noisy breathing (secretions) : 56% pain : 51% agitation/restlessness : 42% urinary incontinence : 32% breathlessness : 22% urinary retention : 21% nausea and vomiting : 14% jerking/twitching : 12% confusion : 9% Macmillan Cancer Support/Medicines Management Network, 2008

Anticipatory Prescribing Advantages - Improved symptom control Reduces stress/anxiety in carers Assists OOH services inexperienced in palliative care Prevents hospital admission Cheaper than OOH visit Patient centered

Anticipatory prescribing Disadvantages - GP’s reluctant to prescribe Need to broach subject of deterioration/dying earlier in patient journey Inconsistencies in prescribing

Anticipatory medicines Morphine Sulphate Cyclizine Haloperidol Metocloprimide Levomepromazine Midazolam Glycopyronium

Medications in dying phase Access to pharmacies OOH Access to pharmaceutical advice OOH Whole team aware of process/resources?

Role of the Key Worker NICE (2004) defines the Key Worker as: “a person who, with the patients’ consent and agreement, takes a key role in co-ordinating the patients care and promoting continuity, ensuring the patient knows who to access for information and advice’.

Key Worker Regular review of residents needs Link between services for a designated resident Lead in the co-ordination of assessment of needs Lead in the co-ordination of care Communicating with resident, relatives, health and social care professionals Ensuring communication within own team of individual resident

End of Life Care Checklist

Summary Co-ordination of care Anticipating Care Sharing information, referral systems Out of Hours Key Worker Anticipatory medication Portfolios, Step 3 To Do List End of Life Care Policy DNAR in advance care planning Evaluations

STEP 3 - CO-ORDINATION OF CARE