To deliver an integrated approach to support patients and their carers sustain care in their own home for end of life care.
Figures produced by ISD show that those in the final year of life accounted for around 30% of all bed days. While 50% of patients continue to die in hospital, Marie Curie can evidence that 98% of those cared for at home with Marie Curie input can be sustained at home.
P&K CHP currently deliver 3 Marie Curie shifts per week for each patient assessed to be in the last 12 weeks of life regardless of diagnosis. Evidence from the last 2 years data shows that existing and predicted increasing demand for enhanced services is no longer sustainable.
How to try and promote awareness and a greater understanding of the 3rd and independent sector to health and council staff.
Promoting the services that third sector and independent sector can and do already provide for older people and how they can prevent avoidable admissions and delayed discharges. Also how to access the organisations and services their, referral systems, costs etc
It is important to look for underlying reasons why people fall and if these are preventable. We know that falls record the highest total length of stay for all admissions and can result in a fracture with the associated loss of confidence and lengthy rehabilitation. Many older people have a ‘community alarm’ and use this to call for help when they have fallen with immediate support provided through the Social Care Response Service (SCRS). Information relating to the call out is gathered by the service and logged, however the information is not shared and other than GP/Emergency service referrals, there is no pathway from the service to falls clinics, etc.
Formal Anticipatory Care Planning and recording were not carried out within the Day Hospital (Medicine for the Elderly). Ensuring that anticipatory care and forward planning are introduced at the most appropriate time in an older person’s life is crucial to planning future care. The team agreed that patients who attended the Movement Disorder Clinic would be most appropriate due to their diagnosis of a degenerative long term condition and in addition these patients are well known to the team and are reviewed regularly.
This project focused on the implementation of Anticipatory Care Planning within all care homes in Lanarkshire and with the Community Nursing Services. This involved updating the ACP documentation, identifying ACP champions within care homes and community nursing and an intensive programme of education to ensure sustainability of the approach and to ensure preferred wishes for care are met.