STEP 3 - CO-ORDINATION OF CARE - PowerPoint PPT Presentation

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STEP 3 - CO-ORDINATION OF CARE. Step 3 - Co-ordination of Care. Objectives: Anticipating care Sharing information - the wider MDT Anticipatory medication Out of Hours The Key Worker Portfolios, Step 3 To Do List End of Life Care Policy Evaluations DNAR in advance care planning.

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Step 3 - Co-ordination of Care


Anticipating care

Sharing information - the wider MDT

Anticipatory medication

Out of Hours

The Key Worker

Portfolios, Step 3 To Do List

End of Life Care Policy


DNAR in advance care planning

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Co-Ordination of Care

Anticipation - key to effective service provision

Effective communication

Information gathering

Information sharing

Ownership, responsibility

Clear plans - shared

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Remember -



Sharing the plan of care, information

Reviewing the plan of care, updating, sharing

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Co-ordination of Care

“If a patient is likely to live for a matter of weeks, days matter, if the prognosis is likely to be days, hours matter.”

End of Life Care Strategy, DH 2008

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Co-ordination of Care

Co-ordination - may require multiple agencies at different times, e.g. home, hospital, care home, hospice

Need to be aware of available services

Co-ordination is a major activity

Whose responsibility? - Can take away from direct delivery of care

Lack of co-ordination = Increased chance of dying in place not of choice

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Co-ordination of Care

Need to consider at different levels:

Within an individual team

Between teams

Across organisational boundaries

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Out of Hours Care

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Why is it important?

In a seven day week, 75% of the time falls OOH

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‘From my own palliative care patients I would hope that I would have them well enough organised in hours that they wouldn’t need to call out of hours.’

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Problems perceived by OOH’s

Lack of information

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Problems perceived by OOH GPs

Lack of information on patient OOH

Workload, time pressures

Unexpected deterioration

Lack of skill/knowledge?

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“Even in the best service/team things go wrong and you can’t always know what’s going to happen. People deteriorate very suddenly… suddenly they think they can’t do it and it’s a crisis.”

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“The easiest thing to do OOH is to send them in – that solves the problem. You don’t have to go back, you know they will be taken care of. I don’t mean to sound cynical about that. You are moving from one patient to the next very quickly in a busy night – these sort of patients need a bit of time.”

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‘The main difficulty is… going into a situation cold and trying to judge everyone’s agenda.’

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What is best for patients?

Effective anticipatory care to reduce the need for OOH calls

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Out-of-hours (OOH) issues

ideally anticipatory prescribing already in place

need to be aware of issues when not in place or unexpected deterioration occurs

OOH can also do anticipatory prescribing – may reduce further visits

good communication needed OOH, especially with family and district nurse team

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Two roads to death

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Managing end of life care (how to avoid the difficult road)






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Anticipating symptoms

How common are symptoms in terminal phase?

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Common symptoms in Terminal Phase

noisy breathing (secretions): 56%

pain: 51%

agitation/restlessness: 42%

urinary incontinence: 32%

breathlessness: 22%

urinary retention: 21%

nausea and vomiting: 14%

jerking/twitching: 12%

confusion: 9%

Macmillan Cancer Support/Medicines Management Network, 2008

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Anticipatory Prescribing

Advantages -

Improved symptom control

Reduces stress/anxiety in carers

Assists OOH services inexperienced in palliative care

Prevents hospital admission

Cheaper than OOH visit

Patient centered

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Anticipatory prescribing

Disadvantages -

GP’s reluctant to prescribe

Need to broach subject of deterioration/dying earlier in patient journey

Inconsistencies in prescribing

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Anticipatory medicines

Morphine Sulphate







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Medications in dying phase

Access to pharmacies OOH

Access to pharmaceutical advice OOH

Whole team aware of process/resources?

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Role of the Key Worker

NICE (2004) defines the Key Worker as:

“a person who, with the patients’ consent and agreement, takes a key role in co-ordinating the patients care and promoting continuity, ensuring the patient knows who to access for information and advice’.

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Key Worker

Regular review of residents needs

Link between services for a designated resident

Lead in the co-ordination of assessment of needs

Lead in the co-ordination of care

Communicating with resident, relatives, health and social care professionals

Ensuring communication within own team of individual resident

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End of Life Care Checklist

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Co-ordination of care

Anticipating Care

Sharing information, referral systems

Out of Hours

Key Worker

Anticipatory medication

Portfolios, Step 3 To Do List

End of Life Care Policy

DNAR in advance care planning


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