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    Microsoft PowerPoint - FINAL FEB JBPathway Presentation ... Microsoft PowerPoint - FINAL FEB JBPathway Presentation ... Presentation Transcript

    • Neurological Conditions Policy Group Neurological Integrated Care Pathway ‘Second Consultation’ Janice Brown 9 February 2007
    • Remit of the working group Develop a neurological integrated care pathway – promote effective, seamless care Resource for professionals – people with neurological conditions who enter the palliative phase NCPC Neurological Policy working group members: Janice Brown, Lucy Sutton, Christina Mason, David Morton, Jan Smith, Acknowledgments: NCPC Neurological Policy group, Delegates at first consultation process (Sept 2006), UK MND Professional network, Rachael Burman and colleagues
    • Today’s presentation Our aims for the ICP Original diagrammatic pathway work (v1) Changes recommended from first consultation Revised diagrammatic pathway work (v2) Invite consultation for the on-going development/practice pilot of the ICP
    • Our Aims for the NCPC Pathway 1. Template for ‘ideal’ care – promote key worker concept 2. Recognise the need for local variations 3. Keep the patient/family at the centre of care decisions 4. For use by professionals 5. Involve all component parts of the patient's journey (pre- diagnosis to palliative care) 6. Support the proactive interface between pivotal services e.g. neurology, palliative care, rehabilitation – neuro-palliative rehabilitation, voluntary agencies, social care 7. Wide spread consultation & pilot in practice
    • Structure of the NCPC Neurological Integrated Care Pathway (ICP v1) A. Two pathway diagrams summarising 1) Pathway to Diagnosis 2) Pathway for Supporting People to Live with a Neurological condition (3 parts) B. Supportive Tools To capture the essential information for the care of people with neurological condition (s), their carers and their families – clarification of key worker role care plan documents C. Evidence base Wide range of evidence supporting the pathway
    • Pathway 1 – pathway to diagnosis v1 Neurological Symptoms G.P. Other specialist – ENT, rheumatologist, Consultant Neurologist gerontologist, psychiatrist, neurosurgeon, etc Out patient or In-patient 2nd opinion investigations: EMG, MRI, Blood, CSF Preparing to tell the diagnosis: Have you Telling the diagnosis/ i) A specialist nurse available to be present? Inform GP providing information/ ii) Asked for a relative to be present? and alert offering treatment iii) A 2 week repeat appoint to offer with consultant/sp nurse? district iv) Vol agency details - MND Ass, MS Society, PDS etc nurse. v) Local guidelines on telling diagnosis? vi) Identified key worker/single point of access to services? Have you made: i) 2/52 repeat appoint with consultant/specialist nurse? ii) Follow-up consultant clinic Go to pathway 2(i-iii) for supporting people to appt for 3/12? live with a neurological condition iii) Initiated key worker allocation?
    • Pathway - Comments In these pathways we are talking about ideals, recognising that services may be limited in what can be offered Neurological conditions vary in presentation but often there are parallels with symptoms and need for services It is very difficult to make some diagnoses; - require a period of further observation - second opinion, may be required
    • Pathway 2 - Pathway for Supporting People to Live with a Neurological Condition v1 The Three Parts: 2i) Diagnosis and Early Specialist Palliative Care referral 2ii) Indicators for Specialist Palliative Care referral 2iii) Indicators for Non-Palliative Care referral
    • PATHWAY 2i) Supporting people living with a neurological condition: Diagnosis and Early Sp Palliative Care referral v1 If you would not If you would not be be surprised if surprised if patient was not patient could not alive in 6-12 communicate months in 6 months Telling the Discuss Advance diagnosis Decisions/Statements & consider Gold Specialist nurse hospital Standards Framework GP appointment Identify KW /single point of & alert contact/case management appointment:. Liaise with District Nurse hospital team/GP & key worker (KW) Consider immediate referral to Specialist Palliative Care Go to 2ii) and 2iii) for indicators for referrals / decisions
    • Pathway 2ii) Supporting people living with a neurological condition: Indicators for Specialist Palliative Care referral v1 Indicators for referrals/decisions for specialist palliative care Breathlessness Swallowing issues, Communication Cognitive difficulties Medical difficulties with eating Complications, issues & drinking, poor pain etc nutritional status Input from co-ordinated (by KW) multi-professional team, SALT, OT, dietician, physio, neuropsychiatry, mental health services, voluntary Impaired ability Yes agencies, genetic counselling, community therapists, continence, pain to make decisions? Consider active management: Consider PEG antibiotic & assisted ventilation feeding tube Life expectancy predicted < 6-12 months Patient wants active management Yes No No, not sure Symptom/ comfort Refer to appropriate management acute service Advance decisions/ Advance Decisions statements for future management Consider Referral to Specialist Palliative Care
    • 2ii) cont…Supporting people living with a neurological condition: Indicators for Specialist Palliative Care referral v1 Consider: Indicators for referrals/decisions for specialist palliative care Quality Of life Cognitive difficulties Breathlessness Swallowing issues, Medical Communication difficulties with eating Complications, issues & drinking, poor pain etc Patient nutritional status Choice Impaired ability Input from co-ordinated (by KW) multi-professional team, SALT, OT, Yes to make decisions? Preferred dietician, physio, neuropsychiatry, mental health services, voluntary Place of agencies, genetic counselling, community therapists, continence, pain Care Consider active management: Consider PEG Life expectancy antibiotic & assisted ventilation feeding tube Predicted No Comfort < 6-12 months Patient wants active management Yes Cont Symptom/ No, not sure Care comfort Assess- Refer to appropriate management acute service Advance Decisions ment Advance decisions/ statements for future management Consider Referral to Specialist Palliative Care
    • 2iii) Supporting people living with a neurological condition: Indicators for Non-palliative Care referral v1 Consider: Indicators for referrals/decisions: Non-Palliative Care Quality Of life Social Emotional Mobility issues issues issues Patient Choice Financial/ Employ- Housing ment issues Preferred Place of Care Family Comfort Psychologist, Input from co- issues: religious ordinated leader, rehabilitation team, Input from Cont counselling physio, OT, social team: Care teams wheelchair care Assess- services, manager, ment motability, grants team, environmental benefits controllers, adviser, Vol spasticity clinic agencies
    • 2ii) & 2iii) Supporting people living with a neurological condition Indicators for SPC & Non- PC referral v1 Consider: Indicators for referrals/decisions Quality Of life Communication Cognitive Mobility issues Social issues Breathlessness Swallowing issues issues difficulties difficulties with eating & drinking, poor nutritional status Medical Patient Emotional Complications, Financial/ Employ- Choice issues pain etc Impaired Housing ment ability issues Input from co-ordinated (by KW) multi-professional team, SALT, OT, to make Input from co-ordinated Preferred dietician, physio, neuropsychiatry, mental health services, voluntary decisions? rehabilitation team, Place of agencies, genetic counselling, community therapists, continence, pain physio, OT, wheelchair Family Care services, motability, Yes issues: Consider active management: Consider PEG environmental antibiotic & assisted ventilation feeding tube controllers, Comfort Life expectancy Input from spasticity clinic social team: predicted Patient wants active management Yes < 6-12 months care Psychologist, manager, No grants team, Cont religious leader, No, not sure Symptom/ Care Refer to counselling teams benefits comfort Assess- appropriate adviser, Vol management ment Advance decisions/ acute service agencies Advance Decisions statement for future management Consider Referral to Specialist Palliative Care
    • The Complete Pathway (v1) Putting 2i, ii and iii together!
    • If you would not If you would not Complete Pathway 2 v1 be surprised if be surprised if patient was not patient could not alive in 6-12 communicate Consultant: Telling the months in 6 months diagnosis Specialist nurse hospital Discuss Advance Decision GP appointment & appointment:. Liaise with hospital Identify KW /single point of team/GP & key worker (KW) & consider Gold Standards alert District Nurse contact/case management Framework Consider immediate referral to Specialist Palliative Care Consider: Indicators for referrals/decisions Quality Communication Cognitive Swallowing issues Mobility issues Social issues Of life Breathlessness issues difficulties difficulties with eating & drinking, poor Medical Financial/ Employ- nutritional status Emotional complications Housing ment Impaired issues Patient issues Input from co-ordinated (by KW) multi-professional team, SALT, OT, ability Choice to make Input from co-ordinated dietician, physio, neuropsychiatry, mental health services, voluntary decisions? rehabilitation team, agencies, genetic counselling, community therapists, continence, pain physio, OT, wheelchair Family services, motability, issues: Preferred Consider active management: Consider PEG Yes environmental Place of antibiotic & assisted ventilation feeding tube Life controllers, Input from Care expectancy spasticity clinic social team: Patient wants active management Yes predicted care Comfort < 6-12 months Psychologist, manager, No grants team, religious leader, No, not sure Symptom/ counselling teams benefits comfort Refer to appropriate adviser, Vol management acute service Cont Advance decisions/ agencies Care Advance Decisions statement for future Assess- management ment Consider Referral to Specialist Palliative Care
    • Main Changes recommended from first consultation 1. Policy: 18 week delivery programme (referral to treatment) 2. Pace of deterioration: Slow and Fast 3. Concept: Neuro-Palliative Rehabilitation
    • Pathway 1 – pathway to diagnosis V2 Neurological Symptoms G.P. Other specialist – ENT, 18 Weeks Delivery rheumatologist, Consultant Neurologist Plan ophthalmologist, gerontologist, psychiatrist, neurosurgeon, etc Out patient or In-patient investigations: EMG, MRI, 2nd Blood, CSF opinion Preparing to tell the diagnosis: Have you Inform Telling the GP and diagnosis/ i) A specialist nurse available to be present? alert ii) Asked for a relative to be present? providing District iii) A 2 week repeat appoint to offer with consultant/sp nurse? Nurse. information/ iv) Vol agency details - MND Ass, MS Society, PDS etc offering treatment v) Local guidelines on telling diagnosis? vi) Identified key worker/single point of access to services? vii) 18 week delivery plan for referrals? Have you made: i) 2/52 repeat appoint with consultant/specialist nurse? ii) Follow-up consultant clinic Go to pathway 2i, appt for 3/12? supporting people to live with a neurological iii) Initiated key worker allocation? condition
    • PATHWAY 2i) Supporting people living with a neurological condition: At Diagnosis and Early Action Considerations v2 Would you be At point of surprised if teling diagnosis patient was not alive in 6-12 months? Identify KW /single Would you be point of contact/case surprised if Yes management No patient could not communicate Inform GP for Specialist nurse hospital in 6 months? appointment & appointment:. Establish alert liaison with hospital Discuss Advance District Nurse team/GP & key worker Decisions & consider (KW) Gold Standards Framework Consider referral to Neuro-Palliative Check Indicators for referrals: Consider referral to Rehabilitation Specialist Palliative Slow deterioration GO TO Pathway 2ii Care: Fast deterioration GO TO Pathway 2iii
    • PATHWAY 2ii) Supporting people living with a SLOW Deteriorating Neurological Condition: indicators for specialist neuro-palliative rehabilitation referral v2 Consider: Indicators for referrals/decisions 18 Week Delivery Complex problems slowly developing with: Mobility and Social Quality Swallowing Emotional / Of life behavioural postural issues issues Nutrition Breathing, tracheostomy / ventilation issues Cognitive issues Patient Communication issues Choice Financial/ Employment Continence issues Housing issues Preferred Input from co-ordinated (by KW) multi- Place of Vocational professional/agency team, SALT, OT, Care dietician, physio, neuropsychiatry, mental rehabilitation health services, voluntary agencies, genetic counselling, community Comfort Psychologist, Input from co-ordinated Family carer support: therapists, continence, pain clinic counselling rehabilitation team, Input from social Cont teams, religion physio, OT, wheelchair team: care manager, Life leader services, motability, grants team, benefits Care Assess- expectancy Yes environmental control, adviser, Vol agencies No ment Predicted spasticity / management, > 6-12 months prevention of deformity GO to 2iii Consider Referral to Neuro-Palliative Rehabilitation
    • PATHWAY 2iii) Supporting people living with a FAST Deteriorating Neurological Condition: indicators for specialist referral v2 Consider: Indicators for referrals/decisions 18 Week Delivery Complex problems Quality Breathlessness Swallowing issues, Medical Communication developing with: Of life difficulties with eating Complications, issues Social issues, & drinking, poor pain etc Mobility and nutritional status Patient Cognitive postural issues Choice difficulties Emotional Input from co-ordinated (by KW) multi-professional team, SALT, OT, behavioural Preferred dietician, physio, neuropsychiatry, mental health services, voluntary Yes issues Impaired ability Place of agencies, genetic counselling, community therapists, continence, pain to make decisions? Care Consider active management: Consider PEG Input (co by KW) Life expectancy antibiotic & assisted ventilation feeding tube from Social Predicted No Comfort No Care team, Rehab < 6-12 months Patient wants active management Yes team, psychologist, Cont Care Symptom/ Yes No, not sure Advance Assess- comfort Consider referral ment Refer to appropriate Decisions management acute service to Neuro - Palliative Advance decisions/ statement for future Rehabilitation management Consider Referral to Specialist Palliative Care
    • PATHWAY 2iv) Supporting people living with a VARIABLE TIMING Neurological Deterioration: indicators for referral for specialist care ( 2ii and 2iii combined, v2) Consider: Indicators for referrals/decisions for specialist care 18 Week Delivery Communication Cognitive Mobility & Social issues Quality Breathlessness Swallowing issues issues difficulties Postural issues Of life difficulties with eating & drinking, poor Employ nutritional status Medical -ment Emotional Complications, Financial/ issues Patient behavioural pain etc Impaired Housing Choice issues ability Voc Input from co-ordinated (by KW) multi-professional team, SALT, OT, to make rehab Input from co-ordinated Preferred dietician, physio, neuropsychiatry, mental health services, voluntary decisions? rehabilitation team, (by Place of agencies, genetic counselling, community therapists, continence, pain KW) physio, OT, Family carer Care wheelchair services, Yes support: Consider active management: Consider PEG motability, antibiotic & assisted ventilation feeding tube Input from environmental control, social team: Comfort Life expectancy spasticity management predicted care No manager, Patient wants active management Yes < 6-12 months Psychologist, grants team, religious leader, benefits Cont Symptom/ counselling teams No, not sure Refer to adviser, Vol Care comfort Yes Assess- appropriate agencies management ment Advance decisions/ acute service Consider referral to statement for future management Consider Referral to Neuro - Palliative Advance Specialist Palliative Care Decision Rehabilitation
    • The complete pathway v2 Merging At Diagnosis Pathway (2i) with Variable Timing Pathway (2iv)
    • Would you be surprised if patient was not At point of telling the diagnosis v2 COMPLETE alive in 6-12 Yes PATHWAY (2i-iv) months? No Would you be surprised if Inform GP & DN patient could not Discuss Advance Decisions communicate & consider Gold Standards in 6 months Identify KW /single Framework Consider referral point of contact/case Specialist nurse to Neuro - management hospital appointment:. Liaise with hospital team/GP Consider referral to Specialist Palliative Care Palliative Rehab & key worker (KW) Consider: Indicators for referrals/decisions 18 Week Delivery Communication Cognitive Swallowing issues Mobility issues Social issues Breathlessness issues difficulties difficulties with eating Quality & drinking, poor Of life Medical Financial/ Employ- nutritional status Emotional complications Housing ment Impaired issues issues Input from co-ordinated (by KW) multi-professional team, SALT, OT, ability Patient to make Input from co-ordinated Choice dietician, physio, neuropsychiatry, mental health services, voluntary decisions? rehabilitation team, agencies, genetic counselling, community therapists, continence, pain physio, OT, wheelchair Family services, motability, issues: Preferred Consider active management: Consider PEG Yes environmental Input from Place of antibiotic & assisted ventilation feeding tube Life controllers, social team: Care expectancy spasticity clinic care Patient wants active management Yes predicted manager, Comfort < 6-12 months Psychologist, grants team, No benefits religious leader, No, not sure Symptom/ counselling teams adviser, Vol comfort Refer to appropriate Cont agencies management acute service Advance Decision Care Advance decisions/ Assess- statement for future ment management Consider Referral to Consider referral to Neuro- Specialist Palliative Care Palliative Rehabilitation
    • We welcome • Your views • What you consider are the relative strengths of the v1 and v2 pathways? (comment sheets in your packs; view posters) • What you consider needs further development? • What would you want to see in the supportive documentation?
    • So, over to you……. Question Sheet Which version (V1 or V2) do you think has most potential for effective care and why? Does your chosen version reflect the complexity of neurological care? Does your chosen version have enough emphasis on co-ordination of care? Is your chosen version useful for professionals only or also patients and carers? Could further time lines be realistically added? Is your chosen version flexible enough to accommodate local variation? Is your chosen version it too complicated? Would it help planning and monitoring care? Would it assist in the improvement of the delivery of care to patients and families?
    • NEXT STEPS……. Consultation Complete the question sheet found in your pack and leave these on your table For supporting docs visit www.ncpc.org.uk Forward ICPs to anyone else you feel should be involved in the consultation To send further feedback or comments please email l.sutton@ncpc.org.uk Pilot sites Let us know if you would like to be involved in piloting the pathway, please indicate on your question sheet
    • Neurological Conditions Policy Group THANK YOU Neurological Integrated Care Pathway ‘Second consultation’ Janice Brown 9 February 2007