AGENDA NO: 6 DATE OF MEETING: November 10th CENTRAL MANCHESTER CLINICAL BOARD Report of: Signed Off By: Design and Delivery Team Members Date of Paper: 3 rd November Subject: Design and Delivery End of Life Care Purpose of Paper: November : To describe the agreed plan of the design and delivery team which will: Specify the specific pathway step change (s) that will be implemented in the six months What the change (s) are Who will be involved How the change (s) will be implemented How the changes will be communicated How the changes will be measured In case of query, please contact: Action required: Sara.fletcher@manchester.nhs.uk 0161 765 4761 Discussion/Decision/Information (Please highlight in bold &underline) Link to: Other Design and Delivery Teams etc If acronyms or abbreviations appear in the attached paper, please list them in the adjacent box. EoLC End of Life Care CMFT Central Manchester Foundation trust DN district nurse ACM - active case manager GSF Gold Standards Framework ACP advanced care plan SaraRadcliffe/doc/clinicalboard/November/eol 1
1 Executive Summary To provide the Clinical Board with the information they need to make a decision as to whether or not to approve the proposed pilot project of the End of Life Care Design and Delivery Team. 2 Introduction The Design and Delivery Team for End of Life Care have focused on improving two key elements of the End of Life Care (EoLC) pathway. 1. Early identification of people in the last year of life 2. Improved assessment, planning and provision of care related to their needs. 3. Improved coordination of care for people in the last year of life 3 Agreed Plan for Specific Pathway Step Changes (s) 3.1 Develop and implement a Prognostic Indicator assessment tool to be used by all health care professionals in Central Manchester to assist with the identification of people in the last year of life. Improved identification of this cohort of people will increase the likelihood of providing better end of life care. 3.2 Improve the discharge planning of in-patients in the last year of life through the Introduction of a management plan proforma which will be completed prior to discharge 3.3 Ensure that End of Life Care is more coordinated by allocating people in the last year of life a key worker who will ensure that their key worker will co-ordinate services on their behalf, ensure their care is seamless, that they are well informed, know where to go to for further information. They key worker will be the focal person that they and their families call on for help and information. 3.4 Increase the number of people in the last year of life who are on the GP Practice End of Life (GSF) register 3.5 Increase the number of people in the last year of life on the End of Life (GSF) register who also have an ACP in place 4 A description of the Specific Steps to be changed 4.1 Develop a Prognostic Indicator assessment tool for use by all health care professionals in Central Manchester 4.2 Develop a management plan proforma to support discharge, management in the community, prevention of readmission and ensure coordinated care 4.3 Identify 2 pilot wards (probably 45 and 46 as already involved with the SHINE project) to test the new pathways and tools 4.4 Train the appropriate CMFT and MCH staff to use the tool and management plan SaraRadcliffe/doc/clinicalboard/November/eol 2
4.5 District Nursing and Active Case Managers to assess their current caseload using the Prognostic Indicator assessment tool 4.6 All in-patients on the 2 pilot wards are assessed using the Prognostic Indicator assessment tool 4.7 The community nursing staff (D/N and ACM) are informed of in-patients on the 2 pilot wards who are in the last year of life 48hrs prior to planned discharge date 4.8 The community nursing staff (D/N and ACM) allocate a key worker from their teams prior to discharge from the 2 pilot wards 4.9 Subsequently the allocated key worker and GP will receive a complete management plan within 24 hours of discharge 4.10 The key worker will register the patient on the GP End of Life Care (GSF) register and discuss the patient in GP MDT meetings 4.11 The EoLC facilitator at CMFT is made aware of all people being discharged from the 2 pilot wards who have been assessed as being in the last year of life 4.12 The EoLC facilitator will work with GP Practices to ensure that all people assessed as being in the last year of life as part of the pilot are placed on the GSF register, discussed in GP MDT meetings and have an ACP in place and collate this data 4.13 Continue to support GP Practices regarding the implementation of GSF and utilisation of end of life tools, end of life pathway documentation and the advance care plan documentation. 4.14 Obtain more information from GP Practices in Central Manchester who opted out of the EoL incentive scheme 2009/10 regarding the implementation of GSF, utilisation of EoL tools, end of life pathway documentation and the advance care plan documentation. 6. Who will be Involved End of Life Care Clinical Lead Central Manchester PBC Hub Janette Hogan Cancer and Palliative Care Lead, NHS Manchester Commissioning Manager Planned Care Central Manchester PBC Hub Kimberley Salmon Davies Divisional Head of Nursing, Acute, Rehab & Emergency Medicine, CMFT Lead Cancer and Palliative Care Nurse, MCH Natalie Neild Acting General Manager (Adults), MCH Jon Simpson Clinical Head of Division, Acute, Rehab & Emergency Medicine, CMFT Rob Davies Clinical Head of Division, Specialist Medical Services, CMFT Assistant Director of Nursing (Adults), CMFT Suzanne Reid CMFT Macmillan Palliative Care Nurse Specialist Community Nursing Representative TBC 6 How the Changes will be Implemented SaraRadcliffe/doc/clinicalboard/November/eol 3
6.1 implementation Action Plan Action Lead/s Timescale Seek authorisation from the Clinical Board to D&D Team December 2010 proceed with the proposed pilot Develop a Prognostic Indicator assessment tool and a management plan proforma Janette Hogan End of Nov 2010 Train CMFT staff to use the Prognostic indicator tool and management plan Roll out the use of Prognostic Indicator assessment tool and management plan to CMFT staff Further education and training for community staff to use the prognostic indicator tool and information regarding the role of the key worker Roll out the use of the Prognostic Indicator assessment tool to community staff; DN/ACM to review their current caseload using the tool Send out a questionnaire to all the GP Practices in Central Hub. Collate, analyse and write up the finding of the GP Practice questionnaire Visit those GP practices who have not returned their questionnaire and make recommendations for the future End of Nov 2010 Rob Davies From Dec 2010 Kimberley Salmon- Jamieson Janette Hogan End of Nov 2010 From Dec 2010 Mid Nov 2010 By Jan 2011 January 2011 Cath Ramnauth Janette Hogan CMFT GSF Facilitator End of Nov 2010 Develop a method through which the project can be audited Collate, analyse and write up the findings March 2011 Make recommendations for the future All April 2011 7 How the Changes will be Communicated The End of Life Care Design and Delivery Team will keep all stakeholders informed throughout the duration of the project as all reps will feedback to their colleagues. 8 How the Changes will be Measured 8.1 The pilot project will achieve the desired targets within the six months and will be measured as followed: SaraRadcliffe/doc/clinicalboard/November/eol 4
Metrics Aim Method of Measurement Target All in-patients on the 2 pilot wards are assessed using the prognostic indicator tool All community nursing (DN/ACM) caseloads are assessed using the prognostic indicator tool All in-patients on the 2 pilot wards who have been assessed as being in the last year of life: Are referred to the community nursing team at least 48hrs prior to discharge to enable allocation of key worker Are allocated a key worker prior to discharge by the community team Are sent home with a complete management plan Made known to the CMFT EoLC facilitator 100% of in-patients are assessed using the prognostic indicator tool 100% of all DN/ACM caseloads are assessed 100% of all in-patients discharged from the 2 pilot wards All people on the community nursing caseload who are assessed as being in the last year of life are made known to the CMFT EoLC facilitator All people identified as being in the last year of life by the pilot are placed on their GP practice register 100% of all people assessed to be in the last year of life 100% of all people assessed to be in the last year of life All people identified as being in the last year of life by the pilot are placed on their GP practice register and have an ACP in place 100% of all people who have been assessed as part of the pilot to be in the last year of life have an ACP 9 Recommendation 9.1 The Clinical Board is asked to approve the plan. Dr Clinical Lead for End of Life Care, Central Manchester PBC Hub SaraRadcliffe/doc/clinicalboard/November/eol 5