What was the issue you were addressing or working on?
To implement ‘Living & Dying Well’ across all settings in Aberdeenshire. A dedicated Project Manager was appointed to facilitate implementation of Living & Dying Well in Aberdeenshire. Previous work had focused on Aberdeenshire Care Homes which had been very successful in raising awareness of the identification, assessment and ongoing review of palliative patients using a facilitative, rather than an instructional approach. This had demonstrated that cross boundary working is possible and positive. There was a need to extend this approach to other primary care, social care, voluntary and independent care settings in order to provide all staff with the confidence they need to carry out effective, person centered palliative care for older people.
What you did?
After the 6 months Care Home Project was evaluated it was agreed to roll out to other areas. An experienced District Nurse (who had been part of the earlier project) was appointed in August 2012 for a 2 year period. The Project Manager continued to support the Care Homes due a significant turnover of staff, managers, RNs. Continuity of care and planning anticipatory care plans for residents continues to be a challenge in the independent care home sector. Numerous teaching/support sessions have been held to support staff and embed NHS Grampian ICP into care homes. The Project Manager is working with Dieticians, DN team managers, MacMillan and Marie Curie nurses, senior charge nurses and care managers; also worked with liaison nurses in secondary care to identity areas of concern in delayed discharges home for end of life care. Teaching packages for carers looking after residents with end stage dementia have been developed with CPNs. Support has been provided in Community Hospitals to introduce the ICP and data gathering. Many of the Community Nursing Teams are now using the PPS as part of the assessment logging it in GSFS reviews and for information transfer. Care Managers too find the PPS a useful tool when referrals are urgent requests.
What were the outcomes - benefits or otherwise?
The support provided allowed more people to remain at home as knowledge, confidence and anticipatory care planning skills of clinicians and carers working in Aberdeenshire care sectors (health, social, voluntary and independent) improved. It prevented unnecessary hospital admissions and reduced the length of stay. It allowed more people to die in their own home if they wished this and supported their carers/family members to enable this