156x Filetype PPTX File size 1.18 MB Source: www.goldstandardsframework.org.uk
Ambulance EMAS Compassionate Hospic Community Respec Churches etc es EEPPaaCCCCSS Respec t x3 t 370 Care OOH/1 homes 11 NEMS Care Patient Co-ordination Indentification Service Strategy Key Performance Indicators – Measuring Quality Please note the KPI’s are to be finalised to ensure the most effective measures are Current service provision included in the model • Non-dependent KPI’s across 5 contracts • KPI’s Do not reflect the whole patient pathway – acute care, social care, third sector, making baseline data analysis redundant • No coordination of KPI’s leading to possible duplication of service • Currently 27% of patient in the last year of life will present at ED • Currently 0.4% of the total population is registered on EPaCCS • 1111 Patients in Mid-Notts died in an acute setting which is 66% of all deaths. Proposed KPI’s – central data source from EPaCCS KPI Threshold % of deaths in preferred place of care A 5% annual increase in the number of end of life care patients that die in their place of choice or usual place of residence (Year 1) Number of patients with written advance care plan or Year one – establish a baseline for all patients with an evidence that an advance care plan discussion has been advance care plan offered Annual % increase until 90% of all patients on the end of life care register have been offered an advance care plan Increase number of patients identified on EPaCCS 0.7% of all patients in year one and continue to Patient Identification maintain Reduction of unnecessary ED attendances to hospital Year one – establish a baseline followed by an agreed for patients at End of Life annual % increase Additional PROMS evaluations will be undertaken to ReSPECT, Patient and Public inclusivity and equity, improve quality to include: bereavement support and patient quality Compliance with KPI’s 6.0 4.5 3.0 1.5 0.0 % EPaCCS pts attending ED Plan 8.0 6.0 4.0 2.0 0.0 %+KPI!$1:$1 of EPaCCS pts attending ED Plan Key Performance Indicators Increase of patients registered on EPaCCS: 2127 patients are registered on EPaCCS Increase in the number of patients with an Advance Care Plan: of the 2127 patients on EPaCCS 1208 have an advance care plan Increase in the number of patients who achieve their preferred place of death: Patients with preferred place of care recorded 82% of patients achieved their preferred place of care Reduction in the number of deaths within four days of admission: Reduction in ED attendances: 585 less attendances from October 2018 to April 2019, compared to compared to baseline period Reduction in Hospital Admission following ED attendance: 288 less admissions from October 2018 to April 2019 compared to baseline period Summary of Notts ICS EOL Workstream Themes and activities in WORKSTREAM (Priorities) Enablers and interdependencies 1 ▪ Workforce: recruit, inspire, Identification of 1 Implement an identification strategy targeting commonly missed groups (e.g. learning disabilities, dementia, retain resilient skilled patients likely to be in non-malignant long term conditions) and incorporating all relevant organisations including care homes and professionals. their last 12 months of community groups Gold Standards Prognostic Indicator Guidance life 2 Initiatives to promote public discussion of dying, death and bereavement to empower the public to identify their own needs and those of each other. e.g. Dying matters week, Death Cafes etc. https://www.dyingmatters.org/ ▪ IM&T: Ongoing resources required and analysis of All patients have the opportunity to complete an advance care plan (ACP) http://endoflifecareambitions.org.uk/ data available to feedback 3 a)Dementia patients should be supported to start an ACP within a year of diagnosis activity to organisations on a b)Those with learning disabilities should be supported to make detailed advance care plans which may require local level 2 best interest decisions multidisciplinary meetings to ensure full MCA compliance Care of the Patient 4 Roll out the ReSPECT process www.respectprocess.org.uk/ ▪ Estates: Personalised care plan A robust sustainable long term strategy for developing IT to facilitate sharing of plans. All organisations should Holistic Symptom be able to access the most recent version of the plan when they need to. Individuals should have easy ▪ Mental health: long waits control 5 access to their own plans. http://endoflifecareambitions.org.uk/ for psychological support, Communication http://www.endoflifecare-intelligence.org.uk/view?rid=787 poor access for those who Care co-ordination Develop a care co-ordination service, directly accessible by patients, carer and professionals. Accessible to are housebound. 6 all identified patients 24/7. This should reduce inappropriate interventions and release resources to increase capacity http://endoflifecareambitions.org.uk ▪ Prevention: Strategy to improve pain control in the home. All patients should have prompt access to measures to 7 effectively control pain and distressing symptoms. Hospice UK No Painful Compromise ▪ Organisations https://www.nice.org.uk/guidance/ng31 – Out of Hours Specialist palliative care should be available 24/7 for those with more complex needs. – 111 Develop a framework for education, training and continuing professional development – EMAS 8 http://endoflifecareambitions.org.uk http://www.goldstandardsframework.org.uk/training-programmes – Social Care 3 End of Life Care educational support to primary care, secondary care and community health care teams rd Support those – 3 Sector Services 9 Identify carers and undertake a carer’s care plan to ensure their needs are met Integrated, collaborative important to the dying person http://www.ncpc.org.uk/sites/default/files/Who_Cares_Conference_Report.pdf relationships required Regular support 10 Increase capacity for care at times and in places that are currently under-capacity. To ensure black and ▪ Community partnerships Respite minority ethnic communities, those in deprived areas, the homeless and imprisoned have equal access to care. – Patient groups Bereavement Care http://endoflifecareambitions.org.uk Enable integrated working via suitable contract that mandate this – Faith/cultural groups 11 Ensure carers are aware of how to access psychological support (pre-bereavement and bereavement care). Develop a ‘Listening Service’ within practices to increase front line access 12 Commission resources/services to promote patient and carer self care Each person is seen as an Each person gets fair Maximising comfort and All staff are prepared Each community is Care is coordinated to care prepared to help individual access to care wellbeing
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