Background The national picture: the NSF for Older People emphasised the need to provide the right care in the right place at the right time. Hospital is not necessarily the best place for older people, unless they are in need of acute medical or surgical intervention (Department of Health, 2001). Admissions are expensive (Department of Health, 2004) and often a frightening experience, particularly to those who are frail and vulnerable; people with advanced dementia are particularly vulnerable and frequently admitted to hospital, often unnecessarily (Department of Health, 2009). In view of this, St Giles Hospice and Douglas Macmillan Hospice are working with South East Staffordshire + Seisdon Peninsula Clinical Commissioning Group to support care homes in providing end of life care to their residents by providing expert support and implementation of key tools to help identify residents in their last 12 months of life.
St Giles and Douglas Macmillan Hospice are supporting care homes throughout their localities by providing a specialist palliative care nurse to help support the home in identifying patients who may be in the last 12 months of life.
Aims and objectives of the service:
Development of a ‘Planning Ahead’ register of frail patients at risk of admission or likely to be in the last 12 months of life, using recognised and evidence based prognostic indicator(s);
To ensure residents on this register have a care plan and advance care plan where appropriate;
To ensure resuscitation status is reviewed for patients and that support is provided for these discussions;
To deliver reduction in the number of avoidable emergency admissions to hospital.
Outcomes and the future Currently St Giles Hospice and Douglas Macmillan Hospice are working with 46 homes providing weekly support sessions and review of the planning ahead register. Data is collated quarterly, with results due the beginning of July 2019.
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