Leading change

The Care Homes Quality Assurance nurses and commissioners at Haringey Clinical Commissioning Group (CCG) led on the development and implementation of a nurse-led Advanced Care Planning facilitator project in care homes. The new initiative complements existing End of Life Care (EOLC) provision in care homes and has delivered improved outcomes, experiences and use of resources, whilst supporting continued high-quality care for those who use the service.

Where to look

NICE (2011) identified that approximately 500,000 people die in England each year and that those with advanced life-threatening illnesses and their families should expect good end of life care, whatever the cause of their condition. Information about people approaching the end of life and about their needs and preferences is not always captured or shared effectively between different services involved in their care, including out of hours and ambulance services (NICE 2011). Up to 74% of people say they would prefer to die at home (National Audit Office, 2008), however 58% of people die in hospital (National End of Life Intelligence Network, 2010) suggesting a discrepancy in personalised care.

The CCG nurses and commissioners conducted a review of Accident and Emergency attendances and non-elective admissions locally within Haringey. This highlighted that nursing home residents had higher than expected episodes with 40% of nursing home residents dying in hospital. This unwarranted variation in place of death and reliance upon emergency services provided the CCG with an opportunity to improve outcomes and experiences of care home residents. Working with care home managers and local EOLC stakeholders, it was identified that there was a lack of Advance Care Planning for care home residents approaching end of life. This was therefore established as the strategic aim.

What to change

Haringey CCG in partnership with Social Finance not-for-profit organisation, local care home providers and North Middlesex University Hospital NHS Trust conducted a benchmarking exercise of End of Life Care (EOLC) Nursing Homes data in Haringey. The results revealed:

• The percentage of people dying in hospitals was greater than those dying in care homes or in the usual place of care (PHE, Fingertips, End of Life Care, 2014);
• London Ambulance data demonstrated that in 2015/16 one of Haringey’s nursing homes ranked 19^th out of 50 London care homes monitored requiring 144 ambulance call outs. The range was 302 callouts (highest) to 107 call outs (50th) per care home;
• Adherence to the Evidence Briefing, Improving outcomes for residents of care homes (2016) which sets out a clear message for both providers and commissioners regarding EOLC needed improving;
• There was partial compliance with the NICE End of Life Care standards (NICE, QS13, 2011) which emphasises the need for training in EOLC, having a senior clinician responsible for the patient, making decisions in conjunction with patients and relatives and ensuring that equipment and staff are co-ordinated;
• Neighbouring boroughs, had achieved reductions in hospital admissions from care homes by investing in clinical services to support care homes.

Based on the benchmarking data, it was agreed to develop a project focussed on Advance Care Planning to achieve the following aims:

• Reduce the number of people having to rely on emergency services in the first one and half years of the project, continuing the increase by a further 10% in subsequent years;
• Increase the number of Haringey nursing home residents who die in their preferred place of care or in the nursing home;
• Enhance staff competencies and confidence in EOLC and ACP;
• Audit to show how further improvements could be made and support ongoing change.

How to change

Clinical commissioning leads along with key stakeholder services agreed to develop the project, funded by Social Finance. Social Finance is a not-for-profit organisation seeking to support the development of services which meet complex social needs, particularly by developing better analysis of needs, service design, investment and the effective management of delivery.

The aim was to develop a model of proactive identification of care home residents for Advanced Care Planning (ACP) and End of Life Care (EOLC). Additionally, the service aimed to increase care home staff competence and confidence in relation to EOLC and ACP. Through training, advice and support, the Advanced Care Planning Facilitation service supports care home staff to:

• Identify adults who are approaching end of life (in the last 12 months of life) and improve their wellbeing;
• Provide training and on-the-job support to care home staff to have ‘Advanced Care Planning’ (ACP) discussions with care home residents and their families and document ACPs as well as co-ordinate aspects of EOLC (liaise with GP, ambulance service, secondary care).

The development and implementation of the project was overseen by a regular Advisory Board consisting of CCG Quality Assurance nurses, commissioners, Local Authority representatives, specialist palliative care clinicians, the ACP Facilitator and Social Finance representatives. Working collaboratively with local partners and Social Finance has enabled the project to achieve its main goals while creating a culture of continuous improvement within the care homes.

As the service has evolved over the last 12 months, the ACP Facilitator and care home staff work closely with local GPs and other key healthcare professionals so that a holistic care plan is developed. As the resident comes towards the end of life, this plan is revisited and preferences and wishes are updated. Staff receive guidance on how to respond to changes in each resident’s condition and support with decision-making if a resident becomes acutely unwell.

Adding value

Better outcomes – In the first year of the project the ACP Facilitator role has started to change the conversations care home staff now have around EOLC and Advance Care Planning. They now have a more holistic approach to interactions and assessments with residents and families. For example, in which situations would they want/not want a hospital admission, their preferences for hydration and nutrition and whether they want to be resuscitated. There has been a notable improvement in outcomes for patients using the service locally, including reduced A&E attendances and higher rates of people dying in their preferred place of death.

Better experience – Residents have been supported to die within the nursing home environment rather than returning to hospital when this decision has been expressed. By having an explicit conversation with residents and/or family members and carers and involving appropriate health care professionals, the nursing home staff are clear about the plan of care and are able to coordinate care according to the residents’ wishes to improve wellbeing at the end of life. Family members have reported that they feel supported during the ACP process, that they know what to expect and feel better prepared.

Better use of resources – The programme focuses on putting residents’ and their families’ wishes at the centre to improve ACP & EOLC practice in care homes. This has had a secondary impact regarding use of resources; there has been a positive impact on A&E resources, ambulance call outs and hospital bed rates for those needing to be in hospital. There has been a significant improvement in the competence and confidence of care home staff to manage residents approaching end of life. The role of the ACP Facilitator has enhanced integrated working and communication between the different healthcare professionals which has resulted in better health and wellbeing for all residents.

Challenges and lessons learnt for implementation

The main challenge is ensuring that all members of the multidisciplinary team understand the Advance Care Plan and that this is supported by effective communication channels.

Staff need to be supported to ask residents and family members what their preferences and wishes are so that they can develop their confidence with potentially challenging conversations; they need to be supported to question decision-making, e.g. whether transfer to hospital will change the outcome for the resident.

A mark of success is demonstrated when staff check for an ACP when a resident becomes acutely unwell or their condition changes, before making any further decisions. The practice of coordinating care according to ACP has therefore been embedded.

Leadership within the care homes and by the ACP Facilitator are both important to integrate the role and practice within the care homes. Empowering nurses and care staff to lead and embed the initiatives is powerful. They are pivotal in understanding the needs of patients and families.

The focus for the next year is to continue to develop the project and use the learning to inform future commissioning of nursing and clinical input in care homes across the borough as well as the STP. The intention is to spread and embed the good practice around Advance Care Planning to improve outcomes for all people approaching end of life.

Find out more

For more information contact:

• Angela Sealy, Care Homes Quality Assurance Nurse Manager, NHS Haringey Clinical Commissioning Group, angela.sealy2@nhs.net
• Priyal Shah, Senior Commissioning Manager, NHS Haringey Clinical Commissioning Group (CCG), priyal.shah@nhs.net