Social Work at Hollywood Private Hospital Hollywood Private Hospital August 2008.
Hospital to home can it work?
Transcript of Hospital to home can it work?
The Royal Marsden
Hospital to home – can it work? Dr Jayne Wood
Consultant Palliative Medicine
The Royal Marsden and Royal Brompton
Palliative Care Service
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Objectives
• Clinical case • What needs to happen? • What are the barriers? • Hospital2Home, RM • Clinical case revisited
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Joan* 65y
• Jul 14: Stage 4a squamous cell carcinoma cervix with local invasion, pelvic
nodes and vesico-vaginal fistula
• Chemo & RT
• Bilateral hydronephrosis (Oct 10/14) with bilat nephrostomies (right side still in)
• Jul 15: Rectovaginal fistula
• Referred for defunctioning colostomy and formation of ileal conduit
• On admission:
• Deteriorating PS for previous 2 weeks (now PS3-4)
• Reduced appetite and poor oral intake (Alb 26)
• PV faecal incontinence
• Symptomatic: abdominal pain, low mood, poor appetite, vomiting
• Renal impairment: Urea 16 Creatinine 135 (baseline 70)
• Urinary symptoms
• Plan: optimisation of clinical condition before considering surgery
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Case cont.
• Social history: • Warden of sheltered accommodation (also her home) • Lives with husband:
• Recent CVA (mood and memory difficulties; residual right sided weakness)
• Under the care of the community neuro-rehab team • Different GP
• 3 foster children (all in Scotland) • Sister (London) • Known to community nursing team • But:
• No POC • Not known to CPCT • Poor relationship with GP
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Case cont.
• Complications during admission: • Poor nutritional state (TPN) • Bilateral hydronephrosis and AKI (left nephrostomy)
• Bacteraemia following nephrostomy insertion requiring vasopressor support
• Urosepsis & ARDS (requiring transfer to CCU for vasopressor support, Abx & NIV)
• Small bowel obstruction secondary to inflammation around fistula • Pelvic collection (drained) • Recurrent disease at vaginal vault invading pelvic side wall
• Not fit for surgery
• Overall poor prognosis
• PPC & PPD = Home
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Considerations for home
• Symptom control • CSCI • Faecal incontinence
• TPN
• Nephrostomies
• PS 4
• Accommodation
• Needs of husband: • Information • Accommodation after death
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What needs to happen?
• Recognition of dying phase
• Communication with patient … and those closest to them: • Clinical condition • Goals of care • Prognosis • Expectations for dying phase
• Review of current treatments with what can be delivered at home in mind • Anticipation of likely events and ACP
• Application for fast track continuing care funding
• Access visit
• Liaison with community professionals • GP • CPCT +/- affiliated services • Community nurses • Marie Curie sitting service • Social care
• Set a discharge date • Book transport • TTOs
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NHS Continuing Healthcare
• Package of care arranged and funded by NHS
• Not means tested
• Pays for healthcare and associated social care needs, and care home fees
• >18y
• Not dependant on disease, diagnosis, who provides care or where care to be provided
• 4 key indicators identify primary health need:
• Nature (characteristics, type and overall effect if needs)
• Complexity (presentation and level of skill needed to manage care)
• Intensity (extent and severity of needs)
• Unpredictability
• Fast track if urgent POC required due to a rapidly deteriorating condition
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What gets in the way?
• Lack of time: • Failure to recognise dying phase or initiate conversations • Acute deterioration
• Reluctance to: • Communicate • Accept equipment, care and/or support • Manage expectations
• Interventions which cannot be supported in community
• Uncontrolled/complex symptoms
• Inappropriate environment
• Pre-existing poor relationship with community professionals
• Coordination of services (in hospital and out!)
• Availability of health and personal support
• …the little things!
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What makes it go well?
• Patient and those closest to them: • Centrally involved • Appropriate expectations
• Good relationships and an understanding of the patient
• Early: • Involvement of MDT to support discharge • Liaison with community professionals
• Key worker to coordinate • Wandsworth care coordination centre! • Comprehensive communication • Arrival of equipment
• Setting a discharge date
• Perseverance
• Open minded
• …when things happen when they are supposed to!
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The Care Coordination Centre, Wandsworth
– Central point of contact
– Based at Royal Trinity Hospice
– Patients with EoLC needs at home or in a care home
– Joined up and responsive care
– Access to a number of services:
– Health
– Personal care support
– Overnight nursing care
– Advice
– Equipment
0300 3000116
7h00 – 22.30 Mon – Fri
9h00 – 17h00 weekends and PH
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The Care Coordination Centre, Wandsworth
– Team:
– Lead Nurse
– Team of coordinators
– SGH Community Nurse for EoLC
– Marie Curie nursing service team
– Health and personal care assistants (with CC FT funding)
– Referral criteria:
– Prognosis <12 months
– > 18y
– Registered with GP in Wandsworth
– Pt consent (or best interests)
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Hospital2Home (H2H)
– 2007
– Aims:
– Aid transition from acute setting
– Increase achievement of PPC and PPD
– Improve communication with community services
– Improve use of acute beds
– More practically speaking:
– Individualised care planning to develop and share with
relevant community HCP’s
– Formally hand over care to the community professionals
– Enable patient and carer to see that information has been
shared
– Anticipate future problems
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Background
– William Marsden (1851):
– “A number of beds are provided for the use of
patients who may remain for life…
– RM often perceived to “hold on” to it’s patients
– H2H:
– Palliative care intervention
– Modelled on a successful research project in
Australia (Abernethy, 2006)
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The team
– 2.6 WTE Band 7 CNSs
– Both sites
– Referral criteria:
– Age > 18yrs
– No further active anti-cancer treatment
– Pt aware of the decision
– Registered with a GP and agrees to involvement of the primary and specialist palliative care teams
– Prognosis (days) – months
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Case conferences
– Telephone
– Face-to-face if:
– No community support or complex relationships
with community HCP’s
– Specific symptom control issues eg bleeding,
repeated bowel obstruction
– Community palliative care teams unable to take
on eg brain tumour patients
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Advance Care Planning
– How they would like to be addressed
– Symptom control and anticipated problems e.g. reaccumulation
of ascites, blood transfusions
– PPC/PPD
– DNACPR
– Clarification of which HCP’s will be involved and their contact
numbers (nb OOH)
– Financial issues
– Social Issues including care packages/safety
– OT assessment
– Psychological/Spiritual needs
– Who to contact if re referral to RM necessary
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Data: Jan 1st 2015 - 21st Oct 2015
– Total number of F2F case conferences: 27
– 13/14 deaths had PPD documented
– 92.3% achieved PPD
– Total no of telephone case conferences: 176
– 72/84 deaths had PPD documented
– 81.9% achieved PPD
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Steps involved in getting Joan* home!
• Symptom control • CSCI community nursing team • SBO & faecal incontinence (octreotide) adjustment of oral intake;
reduced when in bed; NGT for drainage only
• TPN discontinued and oral intake optimised
• Nephrostomies
• PS 4 Care coordination centre in Wandsworth ordered equipment (bed, air mattress, bed leavers, overbed table & sliding sheets) and volunteers from hospice assisted with removing furniture for equipment
• Accommodation access visit with community case manager
• Needs of husband • Professionals meeting with community case manager • Information shared with support of sister • Housing association to arrange transfer to sheltered accommodation
after death
• Fast track continuing care application successful
• CPCT referral
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Why did it work?
• Patient: • Openly discussed preferences for EoLC • Requested discontinuation of TPN • Agreed to discussion with family • Symptom controlled • Accepted limitations at home
• Professionals: • Early commencement of discharge planning:
• 11th Aug: OT/PT assessment in CCU
• 12th Aug: complex case manager attended hospital for prof meeting
• 13th Aug: access visit
• 14th Aug: CC funding approved
• 17th Aug: 24 hour care approved
• 19th Aug: discharged home
• Joint community/hospital meeting • Access visit • Wandsworth care coordination centre
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COMMUNICATION!
COORDINATION!
FLEXIBILITY!