My Health, My Care, My Home - healthcare framework for adults living in care homes: annual progress report September 2023

Palliative and End of Life Care

The Scottish Government is developing a new Palliative and End of Life Care (PEOLC) Strategy for all people in all settings, including care homes. The overarching aims of the strategy, which chime with the framework, are that:

• Everyone in Scotland receives well-coordinated, timely and high-quality palliative care, care around death and bereavement support based on their needs and preferences including support for families and carers.
• Scotland is a place where people and communities can come together to support each other, take action, and talk openly about planning ahead, serious illness, dying, death, and bereavement.

The PEOLC Strategy includes a priority to build, train and sustain the workforce. A new Workforce Education, Training and Resources Working Group has been set up to scope and review professional and multi-agency education and training programmes and resources, in order to identity areas for priority action. This will look across specialist and general clinical and social care in all settings.

At our PEOLC webinar in December 2022 we spoke to care home managers at Beechwood and Rashielee care homes to understand the impact effective palliative and end of life care has on both staff and residents:

Both care home managers highlighted the importance of giving the right care, in the right place, at the right time and reminded us that palliative care is not only about caring for the individual under their care, but also for the friends and family around them to ensure that there is a warm, comfortable environment to allow the resident to die with dignity.

Gathering information, as early as possible (before admission if possible), was particularly highlighted as a vital component in enabling staff to build the knowledge and confidence to speak about PEOLC with residents and their loved ones. This also helps with building relationships, which was also highlighted.

Being able to have open and honest conversations throughout the journey to end of life is so important. Rashielee care home have 3 staff trained in Namaste care which strengthens communication with residents when they are no longer able to communicate verbally. Instead they use sensory to communicate with them. This includes using music, pictures, touch (for example, massaging hands) which gives families comfort that their relative is being well cared for.

One of the recommendations within the framework is that care home providers and specialist palliative care teams should work together to explore shared learning and peer support opportunities, through initiatives such as Project ECHO. This has recently been a key part of the learning networks created in Highland and East Ayrshire. More information on this can be found in our Skilled and Sustainable Workforce chapter.

The framework also highlights the importance of the Scottish Palliative Care Guidelines as a source of practical evidence based on best practice guidance for people delivering palliative and end of life care. The guidelines have been embedded as part of Healthcare Improvement Scotland’s (HIS) SIGN Guidelines so that this resource can be continually reviewed, improved and updated.

The new strategy will also prioritise and address timely, all-hours access to care and advice, and medicines and equipment, which are necessary to ensure that staff in care homes can respond promptly to any changes in a person’s condition and in line with a person’s preferences recorded through Future Care Planning.

Marie Curie have also established a Care Home programme which aims to work in collaboration and partnership with key stakeholders to influence and support sustainable system-wide delivery of consistently high-quality end of life care in care homes across Scotland. We are members of the Care Home Programme Reference Group which is supporting this work.

One of the key strands of work is the development of a PEOLC Network for the Collaborative Care Home Support Teams across Scotland. The network will seek to enhance the capacity and impact of external PEOLC expertise going into care homes and to maximise the potential of these on-the ground professional relationships, with the ultimate aim of empowering care home staff in the delivery of PEOLC.

Additionally, Scottish Ambulance Service (SAS) and MacMillan have embarked on a project to improve the PEOLC provided by SAS staff and thus improve patient / carer experiences by reducing the number of people being taken to hospital. To do this they are creating alternative pathways to admission to hospital by developing professional to professional communication pathways that avoid unnecessary hospital admissions, and they are also developing an education programme for staff. As of June 2023, test sites in Forth Valley, Ayrshire and Arran, and Grampian were reporting conveyance rates of 67%, 54% and 63% respectively with the most likely causes of these being: strokes, unconsciousness, falls and breathing problems.

Urgent and Emergency Care

Accessing responsive and appropriate care in an urgent or emergency situation is important for people living in care homes.

As noted in our MDT chapter, many areas in Scotland have recruited Advanced Practitioners to respond to the urgent care needs those in care homes. This includes Advanced Nurse Practitioners (ANPs) who have a primary remit to deliver care and build relationships with those who are living in care homes to provide direct, clinical support.

Scottish Ambulance Service is undertaking focused improvement work in several areas of Scotland. Following a 999 call to a care home, the paramedic staff are providing an urgent response and assessment within the home, then where appropriate are liaising with other members of the MDT to help avoid unnecessary admissions to hospital. In another pilot SAS is working with the charity Macmillan to respond to the urgent needs of people who are nearing the end of life in care homes.

Other areas have introduced dedicated professional to professional lines to support urgent care. At our webinar on urgent and emergency care we heard from colleagues in Fife HSCP about the professional to professional phoneline they are trialling which provides care homes with direct access to urgent care services. As of August 2023, 54 care homes (out of 75) were using this line and Fife HSCP are working with the others to get them on board too. Their latest data showed that only around 3% of calls resulted in a hospital admission, and there was an overall sense that care has been improving as the team grow in confidence around the processes.

NHS 24 are supportive of pathways like this as they have data to show that most calls to them from care homes are passed onto the out of hours services anyway. There is however caution from some of the health board out of hours services, who are worried about capacity to answer calls directly from care homes. We have been holding discussions with NHS 24 and Out of Hours services to explore this further.

Through the Urgent and Unscheduled Care Programme, Scottish Government have established local Flow Navigation Centres in every NHS Board which are designed to deliver 24/7 access to a senior clinical decision maker. This can play a role in providing the right care, at the right place, at the right time as Flow Navigation Centres can act as a point of contact for care homes when there is an urgent healthcare issue.

Ayrshire and Arran have introduced such a pathway, whereby care home staff can contact a senior clinician working within their Flow Navigation Centre during the out of hours period as an alternative to calling NHS 24. They now handle over 500 calls per month from care homes. Since introducing this pathway staff spend less time on the phone trying to access help, and there are fewer calls to Scottish Ambulance Service and fewer transfers to hospital. Their data show that only 10% of calls to the Flow Navigation Centre require the person living in the care home to attend hospital for further intervention. Good working relationships have been established between care home staff, call handlers, and clinicians in the service, which has been helpful to build confidence and trust for decision making.

A new Flow Navigation Centre Speciality Delivery Group (SDG) has been established by the Centre for Sustainable Delivery (CfSD) which will focus on enhancing the pathway including to improve professional to professional access, such as care homes, which will support reduced admissions to hospital. The SDG will aim to reduce unwarranted variation by standardising service provision and pathways on a best-of-class and once-for-Scotland basis wherever possible.

Improving transitions of care

Over the past year we have also explored the various programmes of work taking place across the sector to improve communication and sharing of information between professionals.

Laurels Lodge care home in Grampian told us about their use of the Hospital Passport which they have been using to great effect to ensure salient information arrives at the hospital with their residents. Feedback from staff highlighted use of the passport has reduced the number of calls from hospitals seeking more information about patients.

‘Red bags’ are a great concept that have been used to varying degrees of success across the country over the years.

When they are used well there is improved communication and the transition of care in and out of hospital is smoother. However, feedback from care home managers was that it’s often not an effective system and so the general uptake by care homes and hospitals has been slow.

More recently, NHS Ayrshire and Arran have been piloting a cabin style suitcase which includes the patient’s anticipatory care plan, KIS, medical notes and other relevant information. As of June 2023, 41 of the 63 care homes in the area are now using the red bags, transfer document and yellow alert card. Providers and Acute colleagues continue to support the rolling out of the initiative, along with a transfer document that provides pertinent resident/patient information for staff during discharge or admission. The intention is to continue spreading this document along with Alert Cards and a checklist of itemised personal belongings that will stay with the resident throughout their admission to hospital and return with the resident to their care home.

NHS Lanarkshire have instead been trialling a patient transfer document with five care homes to improve the individual’s journey with better communication and prevent discharge failures. This has proven to be a challenge to implement across all acute sites in the region, but the team are focusing on, and making progress in, elderly care wards and community.

The Care Home Liaison Team (CHLT) in Highland developed the Home Safe poster following a number of engagement events to understand hospital discharge experiences of care home residents, staff and providers. The poster has been put on display in ward areas across the region and has brought about greater levels of consistency for all staff when arranging and facilitating discharge.

The CHLT also started proactively following up every hospital discharge within 24 hours, which allowed them to gain an overview of themes and trends and offer targeted support to discharging areas. This has improved discharge experiences and increased partnership working between care homes and hospitals.

Furthermore, each area now has a ‘decision making team’ who collaborate with the Discharge Team / Wards to ensure safe and effective discharge. The team meet daily and have oversight of care home discharges in their areas. This has supported flow locally as care homes and local decision making teams have stronger relationships, and it has also reduced the burden on care homes receiving multiple calls from discharging areas.