Wirral Specialist Palliative Care Service

Transcription

1 Wirral Specialist Palliative Care Service Operational Policy Agreed date: 25 th September 2012 Review date: 25 th September 2013

2 Specialist Palliative Care Multi-disciplinary Team This Operational Policy has been agreed by: Position: Lead Clinician of the MDT (and joint Host organisation) Name: Cathy Lewis-Jones Organisation: Wirral Hospice St John s Date agreed: 25th September 2012 Position: Lead Clinician of the Host organisation Name: Ewen Sim (Medical Director) Organisation: Wirral Community NHS Trust Date agreed: 26 th September 2012 Position: Core Nurse Members of the MDT (12-3R-112) Name: David Woods, Dawn Miller, Karen Radley and Liz Watkins Organisation: Wirral Community NHS Trust Date agreed: 24 th September 2012 MDT Members agreed this document on 24 th September /14

3 Contents Number Measure Page 12-3R-101 Lead Clinician and Core Team Membership R-102 Level 2 Practitioners for Psychological Support R-103 Support for Level 2 Practitioners R-104 Attendance at NSPCG Meetings R-105 SPCMDT Meeting R-106 SPCMDT Agreed Cover Arrangements R-107 Core Member (or cover) Present for 2/3 of meetings R-108 Annual Meeting to Discuss Operational Policy R-109 Operational Policy for MDT Discussion R-110 Operational Policy for Key Worker R-111 Specialist Training for Core Nurse Members R-112 Agreed Responsibilities for Core Nurse Members R-113 Attendance at Advanced Communications Training Programme 12-3R-114 Extended Membership of SPCMDT R-115 Patient's Permanent Consultation Record R-116 Patient / Carer Experience Exercise R-117 Provision of Written Patient Information R-118 Management Planning Decision R-119 SPCMDT Agreement to Network Guidelines on Criteria for Referral to a Specialist Palliative Care MDT 12-3R-120 SPCMDT Agreement to Network Clinical Guidelines R-121 SPCMDT Agreement to Network 24hr Telephone Advice Service Specification 12-3R-122 SPCMDT Agreement to 7 Day Visiting Service 12 Specification SPCMDT Agreement to Network Education and Training 12-3R-123 Plan R-124 Network Audit R-125 Discussion of Clinical Trials /14

4 1. Introduction The Specialist Palliative Care (SPC) Service in Wirral is jointly provided by two organisations: Wirral Hospice St John s (WHSJ) and Wirral Community Trust (WCT) to form one multi-disciplinary team which serves the population of 309,000. The service is available to all adult Wirral residents and non-residents registered with a Wirral GP. WHSJ, as the local SPC in-patient unit, hosts the consultants in Palliative Medicine who are supported by medical, nursing and allied health professionals (AHPs) to deliver in and out-patient care, day care, domiciliary care and Hospice at Home. The consultants contracts of employment are held by Wirral University Hospitals Foundation Trust (WUTH) where in-patients sessions and an out-patient clinic are also delivered. WCT hosts the Integrated Specialist Palliative Care Team (ISPCT) which comprises specialist palliative care nurses and AHPs with admin support. The ISPCT is responsible for delivering specialist palliative care to patients whether they are in hospital, the hospice, care homes or out-patient settings. 2. MDT Meetings Due to this configuration, in which the acute trust does not have its own SPC team, the Multi-disciplinary Team meetings are made up of a combination of SPC team members from the two different organisations. Therefore the two SPCMDT meetings being put forward in Wirral for Peer Review are: Integrated SPCMDT meeting held on Wednesday mornings at WHSJ This meeting deals with hospice in-patients, out-patients, day-care or Hospice at Home patients and those patients under the care of the community-based ISPCT members that meet the network criteria for MDT discussion. Acute trust SPCMDT meeting held on Friday mornings at WUTH This meeting deals with relevant in-patients at WUTH under the care of the SPC team that meet the network criteria for MDT discussion. The ISPCT also holds weekly locality meetings to discuss their particular patients but these do not constitute SPCMDTs as per the guidelines and are therefore outside the measures for Peer Review. 3. Patient Pathway All health and social care service providers in Wirral, including the Specialist Palliative Care Team, use the Wirral Integrated End of Life pathway, below, to denote the stage that a patient is at during their end of life phase and to initiate appropriate end of life tools and the correct anticipatory care. This is based on the Northwest end of life model but has been redesigned into a patient pathway format to include the stages from diagnosis to death. 4/14

5 Wirral Integrated End of Life Pathway CANCER/ LTCs End of Life Curative / Stable Non-curative / Progressive GSF ACP LCP Diagnosis Treatment Outcome/ Follow Up Advancing disease Palliation (Increasing decline) Dying (Last days of life) Keyworker Keyworker Patient pathway based on key milestones 4. Purpose of MDT Aims: Provision of a comprehensive specialist palliative care service in line with the Supportive and Palliative Care for Adults with Cancer guidance (NICE, 2004), the End of Life Care Strategy (DH, 2008) and NICE Quality Standards (NICE, 2011) Provision of timely, effective, multi-disciplinary specialist palliative care, advice and support to patients with advanced, progressive disease Prevention of inappropriate or unnecessary hospital attendance, admission or death through proactive assessment and management of patients palliative care needs Objectives: The SPCMDT is committed to achieving the highest standards of care and patient outcomes by: Holistic assessment of patients physical, psychological, spiritual and social needs at key stages at any stage in trajectory, with a clear plan of care Development of individualised care plans with clearly defined outcomes for each patient Accurate anticipation and identification of changes in patients palliative care needs to ensure they are addressed in a timely manner Delivery of care in the most appropriate place, when possible close to a patient s home/residence Support for patients preferences regarding their preferred priorities of care and place of death 5/14

6 Cross-boundary working to coordinate patient care and facilitate timely hospital / hospice admission or discharge Provision of specialist palliative care advice and support to health and social care colleagues Partnership working with other agencies to avoid delays or duplication of effort / resources (e.g. equipment) Commencement of syringe driver-delivered analgesia within 4 hours of prescribing Facilitating the rapid discharge to die process for those patients wishing to die elsewhere Accurate assessment of carers needs with referral for appropriate support Development and implementation of relevant Peer Review documentary evidence and an Action Plan as per the Quality Standards Development of community-based SPC clinics as an alternative to home visits Provision of palliative care education and training across health/social care providers in line with the MCCN Education and Training Strategy ( ) 5. Leadership Arrangements 12-3R-101 The Lead Clinician is Dr Cathy Lewis-Jones and agreed responsibilities include: ensuring that objectives of MDT working (as per Manual of Cancer Services) are met ensuring that specialists work effectively together in teams such that decisions regarding all aspects of diagnosis, treatment and care of individual patients and decisions regarding the team's operational policies are multidisciplinary ensuring that care is given according to recognised guidelines (including guidelines for onward referrals) with appropriate information being collected to inform clinical decision making and to support clinical governance / audit ensuring mechanisms are in place to support entry of eligible patients into clinical trials, subject to patients giving fully informed consent overall responsibility for ensuring that MDT meetings and the team meet peer review quality measures ensuring attendance levels of core members are maintained, in line with quality measures providing link to NSPCG either by attendance at meetings or by nominating an MDT member to attend leading on, or nominating lead, for service improvement organising / chairing annual meeting, examining functioning of team and reviewing operational policies and collating any activities that are required to ensure optimal functioning of the team (e.g. training for team members) ensuring MDT's activities are audited and results documented ensuring that the outcomes of the meetings are clearly recorded and clinically validated and that appropriate data collection is supported ensuring target of communicating MDT outcomes to primary care is met 6/14

7 Dr Lewis-Jones is also responsible for ensuring that recruitment into clinical trials and studies is integrated into the function of the MDT. 6. SPC Multidisciplinary Team Membership arrangements 12-3R-101 The core MDT members will be listed to correspond with the two separate SPCMDT meetings that take place. The consultants job plans can be viewed in the evidence file. Integrated SPCMDT meeting at Wirral Hospice: Name Role Dr Cathy Lewis-Jones* Lead Clinician / Consultant in Palliative Medicine Dr Helen Emms Consultant in Palliative Medicine Dr Fawad Ahmad Consultant in Palliative Medicine Karen Radley Clinical Nurse Specialist Dawn Miller Clinical Nurse Specialist David Woods Clinical Nurse Specialist Maria Lyon # AHP (OT) Alice Meehan MDT Co-ordinator Key: * = lead for clinical trials: # = lead for patient /carer issues and information SPCMDT meeting at Wirral University Teaching Hospital: Name Role Dr Cathy Lewis-Jones* Lead Clinician / Consultant in Palliative Medicine Dr Helen Emms Consultant in Palliative Medicine Heather Aitken # Clinical Nurse Specialist Liz Watkins Clinical Nurse Specialist Lisa Brett AHP (OT) Lois Barnes MDT Co-ordinator / Secretary Key: * = lead for clinical trials: # = lead for patient /carer issues and information 7. MDT Cover Arrangements 12-3R-106 Cover arrangements for each core team member is listed in the tables below. Integrated SPCMDT meeting at Wirral Hospice: Name Role Named Cover Dr Cathy Lewis-Jones Lead Clinician / Dr William McManus Consultant in Palliative Medicine LAS Registrar Dr Helen Emms Consultant in Palliative Medicine Dr William McManus LAS Registrar Dr Fawad Ahmad Consultant in Palliative Medicine Dr William McManus LAS Registrar Karen Radley Clinical Nurse Specialist Teresa Smith Dawn Miller Clinical Nurse Specialist Sheila Nugent David Woods Clinical Nurse Specialist Cheryl Parrington Maria Lyon AHP (OT) Alex Watts (physio) Alice Meehan MDT Co-ordinator Hannah Ward 7/14

8 SPCMDT meeting at Wirral University Teaching Hospital: Name Role Named Cover Dr Cathy Lewis-Jones* Lead Clinician / Dr William McManus Consultant in Palliative Medicine LAS Registrar Dr Helen Emms Consultant in Palliative Medicine Dr William McManus LAS Registrar Liz Watkins Clinical Nurse Specialist Rotation Nurse from ISPCT Heather Aitken Clinical Nurse Specialist Rotation Nurse from ISPCT Lisa Brett AHP(OT) Diane Jones (Physio) Lois Barnes MDT Co-ordinator / Secretary Christine Jackson (Senior Admin Support) Due to the monthly rotation of ISPCT nurse members the named cover for a CNS will not always be the same person but will be the current locality nurse member working within the acute unit that month. For that reason names have not been inserted into the relevant rows above. However there will always be a minimum of two CNSs present for each SPCMDT within the acute trust. Core member (or cover) to attend 2/3 of all MDT Meetings 12-3R-107 All health care providers involved in the core group are expected to attend and non core members are actively encouraged to attend on a regular basis. All meeting attendees who attend in person sign the attendance record for each meeting. Attendance records for the two SPCMDTs can be found in the evidence file. 8. Psychological Support 12-3R-102 The core team members who have completed training to practice level 2 psychological supports of cancer patients and carers are: Karen Radley Liz Watkins 12-3R-103 Name Role Clinical Nurse Specialist Clinical Nurse Specialist Monthly level 4 clinical supervision has recently been commissioned for the level 2 practitioners / core members. A service specification details the requirements for this service. The dates and times for the first six month s sessions are in the evidence file. 9. Extended Team Members 12-3R-114 8/14

9 The extended members of the SPCMDTs who have agreed by the lead clinician as a contact point and will attend the MDT S as required are as follows: Integrated SPCMDT meeting at Wirral Hospice: Name Role Contact Details On rota in Community All ISPCT CNS s and SNP s On rota in WHSJ All band 6 nurses Jerry O Sullivan Inpatient Social Worker Maddie O Loughlin Community Social Worker Helen Hardwick Psychological Support George Palmer Chaplin Sharon Woodward Bereavement Support Cheryl Currie Pharmacist Dr Andrew Jones Pain Specialist Dr Geraldine Swift Consultant in Psychological Medicine SPCMDT meeting at Wirral University Teaching Hospital: Name Role Contact Details On rota for WUTH All CNS s and SNP s from ISPCT Maddie O Loughlin Social Worker Andrew Scaife Chaplin Ext 2275 Dr Richard Griffiths Consultant in Acute Oncology ext 2920 Dr Andrew Jones Pain Specialist Dr Geraldine Swift Consultant in Psychological Medicine Jackie Edwards Pharmacist Sue Brown Cruse Bereavement support Core Nurse Members Specialist Study 12-3R-111 Details of the specialist study undertaken by core nurse members is listed below with certificates placed in the evidence file. Name Course Year attended Karen Radley Advanced Award in Palliative Care 1995 Dawn Miller Master of Science in Palliative Care 2012 David Woods Care of the Dying 2012 Heather Aitken Dissertation in Palliative Care 1993 Liz Watkins Dissertation in Palliative Care Core Nurse Members Responsibilities 12-3R-112 The responsibilities for the core nurse members agreed by the lead clinician include: contributing to the multidisciplinary discussion and patient assessment / care planning decision of the team at the regular MDT meetings 9/14

10 providing expert nursing advice and support to other health professionals in specialist palliative care involvement in clinical audit leading on patient and carer communication issues and co-ordination of the patient pathway for patients referred to the team - acting as the key worker or responsible for nominating the key worker for patients dealing with the team ensuring that results of patients holistic needs assessments are taken into account in the decision making contributing to the management of the service utilising research in specialist palliative care 12. Advanced Communications Skills Course 12-3R-113 The core team members of the SPCMDT with direct patient contact who have attended (or are booked to attend) the national Advanced Communications Skills Course are listed in the following table: Name Role Date attended Dr Cathy Lewis-Jones Lead Clinician / Consultant in July 2006 Palliative Medicine Dr Helen Emms Consultant in Palliative Medicine Booked for 21 st / 22 nd March 2013 Dr Fawad Ahmad Consultant in Palliative Medicine 2011 Karen Radley Clinical Nurse Specialist Sept 2009 Dawn Miller Clinical Nurse Specialist July 2009 David Woods Clinical Nurse Specialist July 2009 Heather Aitken Clinical Nurse Specialist July 2009 Liz Watkins Clinical Nurse Specialist June 2011 Maria Lyon AHP (OT) April 2010 Lisa Brett AHP (OT) Dec MDT Attendance at NSPCG meetings 12-3R-104 Dr Lewis-Jones is the nominated clinical lead who attends the NSPCG meetings with Julie Gorry also attending as WHSJ Chief Executive. Wirral SPCMDT s attendance at the NSPCG meetings can be seen in the evidence file. 14. MDT Meetings 12-3R-105 The Integrated SPCMDT meetings are held every Wednesdays at WHSJ between 9.30am pm. Attendance is recorded by means of an attendance sheet which the MDT coordinator is responsible for completing and collating. The Acute trust SPCMDT meetings are held every Friday at WUTH between 9.30am 12.30pm. Attendance is recorded by means of an attendance sheet which the MDT coordinator is responsible for completing and collating. 10/14

11 Patients that require a care planning decision before the next scheduled meeting are dealt with according to the following procedure (see evidence file): Telephone discussion with the relevant treating consultant or their deputy Formal written letter to follow telephone discussion as a permanent record The patient will be discussed at the next scheduled SPCMDT meeting 15. Operational Policy for MDT Discussion 12-3R-109 The Operational Policy for MDT discussion can be found in the evidence file. Patients are listed for discussion at the SPCMDT meetings if they meet the following criteria: All new patients to the service that week (within past 7 days) Patients of particular concern to any SPC team member Patients where a team member seeks the support/advice of the rest of the team Patients who are about to cross a care boundary within Wirral Patients who need the skills of the MDT to remain in their desired place of care Patients who have died or been discharged from the service The focus of the MDT discussion will include: 1. Name 2. Diagnosis/Disease extent 3. Estimated prognosis i.e. where on End of Life Care Pathway 4. PPC 5. Outcome of discussion and Management Plan The MDT coordinator is responsible for ensuring the list of patients is generated, based on in-put from the clinical team members, in advance of the meeting. 16. Individual Management Plans 12-3R-118 Following SPCMDT s discussion the outcome of individual patient s management plans are recorded by a core member of the MDT on the outcome sheet which includes the identity of patients discussed and the multi disciplinary treatment planning decision. This is placed in the patient s case notes by the MDT Co-ordinator. Anonymised examples can be found in the evidence file. A copy of the SPCMDT meeting outcome is faxed to the relevant health and social care professionals involved in the patient s care. The patient is informed of the outcome of the discussions by the key worker and this is documented in the patient s case notes. 17. Operational Policy Meeting Arrangements 12-3R-108 An Operational Policy meeting was held for the ISPCT members on 16 th April 2012, 11/14

12 prior to the publication of the final Peer Review measures, to discuss their specific operational issues. However, the final measures have led to a re-configuration of the SPCMDT meetings and therefore a subsequent meeting, for the whole Wirral SPCMDT, was held on 3 rd October 2012 in order to disseminate the revised NSPCG guidelines and discuss how these might impact on the function of the team (see Annual Report). 18. Key Worker Policy 12-3R-110 SPC team members do not often act as the key worker for patients, due to the advisory nature of the service, and the assigned key worker may change with the patient s circumstances, condition and individual needs. However it is important for the patient and their family / carers and all relevant professionals to be aware of whom the key worker is at any one time. The key worker policy can be found in the evidence file which documents the process for agreeing, recording and disseminating details regarding any changes to the key worker whilst the patient is under the care of the SPCMDT. 19. Clinical and Referral Guidelines 12-3R-119 Wirral SPCMDT has agreed the Network Guidelines on Criteria for Referral to a Specialist Palliative Care MDT attached below R-120 Wirral SPCMDT has agreed the Network Clinical Guidelines R-121 Wirral SPCMDT has agreed the Network 24hr Telephone Advice Service Specification R-122 Wirral SPCMDT has agreed the Network 7 Day Visiting Service Specification The above guidelines have been circulated to the site specific MDTs at WUTH with contact details for the SPC team, in and out-of-hours, attached. 20. Education and Training 12-3R-123 Wirral SPCMDT has agreed the network training and education strategy. The Wirral has End of Life facilitators in the CT and hospital trust as well as a Wirral-wide 12/14

13 education facilitator based at WHSJ. These facilitators share responsibility for education and training with the SPCMDT members. 21. Audit 12-3R-124 The SPCMDT has agreed to participate in the network audit programme agreed by the NSPCG. A member of the SPCMDT participates in the regular MCCN Audit Group which feeds back to the NSPCG. The MDS is compiled separately by WCT and WHSJ. Local audits undertaken include: PAIL audit (across WCT and WHSJ) Blood Glucose monitoring for patients on Steroids (WHSJ) 22. Patient/Carer Information, Feedback and Involvement 12-3R-116 Patient / carer feedback is obtained using a variety of tools such as: Patient surveys/questionnaires Comments boxes Service visits Results of the above, and a report on the actions taken, can be found in the evidence file. 23. Patient Information 12-3R-117 The SPCMDT is not currently using the NHS Information Prescriptions. Examples of the types of information given to patients and their families can be found in the evidence file. These include details of local provision of specialist palliative care services and management and care options. Patients are referred for psychological support if, following assessment, this is deemed necessary. However, leaflets regarding the service are not routinely distributed. A carers group is run by WHSJ for those wishing to participate (see poster). 24. Patient Permanent Record 12-3R-115 All patients are offered a permanent record or a summary of their clinical consultation. A Record of Consultation leaflet has also been developed to be used across the SPCMDT in order for patients to be given a hand-held summary. This is currently in use within the hospice setting and is being piloted by the Community Trust s SPC members. An example of a completed record can be found in the evidence file. 25. Discussion of Clinical Trials 13/14

14 12-3R-125 Professor John Ellershaw is the Network Clinical Lead for clinical trials There is a national portfolio of SPC clinical trials. Currently there are no patients within the network recruited into the national trials. This will feature in the work programme for the clinical network group and the SPC MDTs. 14/14