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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

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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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 -

Consent

Documentation

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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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 I would have them well enough organised in hours that they wouldn’t need to call out of hours.’

Lack of information


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Problems perceived by OOH GPs I would have them well enough organised in hours that they wouldn’t need to call out of hours.’

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? and trying to judge everyone’s agenda.’

Effective anticipatory care to reduce the need for OOH calls


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Out-of-hours (OOH) issues and trying to judge everyone’s agenda.’

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 and trying to judge everyone’s agenda.’


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Managing end of life care (how to avoid the difficult road) and trying to judge everyone’s agenda.’

anticipation

co-ordination

explanation

comfort

support


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Anticipating symptoms and trying to judge everyone’s agenda.’

How common are symptoms in terminal phase?


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Common symptoms in Terminal Phase and trying to judge everyone’s agenda.’

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 and trying to judge everyone’s agenda.’

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 and trying to judge everyone’s agenda.’

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 and trying to judge everyone’s agenda.’

Morphine Sulphate

Cyclizine

Haloperidol

Metocloprimide

Levomepromazine

Midazolam

Glycopyronium


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Medications in dying phase and trying to judge everyone’s agenda.’

Access to pharmacies OOH

Access to pharmaceutical advice OOH

Whole team aware of process/resources?


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Role of the Key Worker and trying to judge everyone’s agenda.’

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 and trying to judge everyone’s agenda.’

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 and trying to judge everyone’s agenda.’


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Summary and trying to judge everyone’s agenda.’

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

Evaluations


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