Anticipatory Care Planning + e-PCS


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Anticipatory Care Planning using the electronic Palliative Care Summary

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  • A journey… This is taken from a folding kayak, starting to paddle the length of Loch Ness Patients have journeys, and at times they feel unprepared, esp. at transitions eg OOH or between community &Hospital
  • The maze of trees -by Michel Petroni see MAP Foundation Artist who painted his journey with Hodgkin’s disease. I'm confused. I'm lost as to which way to turn - who to turn to. Before, everything seemed so clear. Now, which way to turn, which path to follow? Help me, please somebody show me the way. I had an exhibition on then, called Into the light. It was designed as a celebration of my restoration to health - but in fact it marked my relapse. Was the light, into which I might be going, the great celestial light?
  • Examples of screenshots This is std EMIS Summary page 84 yr man with extensive med Hx Lung cancer and widespread mets
  • This is GSFS Screen – no diagnosis chosen yet
  • The malignancy plus diabetes are added for sending OOH
  • This screen shows pts wishes
  • 100 years ago people what do we die of It used to be. It used to be…now top 3 causes can be grouped as. These are the choices we have today: organ failure HF, lung failure, COPD, liver failure, kidney failure
  • These are how people die, nowadays Out of 20 death, 5, 6, or 7. Which group would you? You may wish to be in 2..not realistic option 3 trajectories Cancer has all the good stories But focus
  • summary
  • We started our journey on Loch Ness – a wonderful water feature in creation. This is the man-made Falkirk wheel – where in Scotland we have made water go uphill! Let’s continue to strive to offer our patients and their families the best possible care – even when it looks difficult – after all in caring for dying patients, we only get one chance!
  • Anticipatory Care Planning + e-PCS

    1. 1. Anticipatory Care Planning using the electronic Palliative Care Summary (ePCS) August 2010 Dr Peter Kiehlmann GP, Aberdeen & National Clinical Lead Palliative Care eHealth [email_address]
    2. 2. Questions? <ul><li>What is ePCS? </li></ul><ul><li>Who can use it? </li></ul><ul><li>How does it help </li></ul><ul><ul><li>Patients & carers </li></ul></ul><ul><ul><li>Staff </li></ul></ul><ul><ul><ul><li>In-hours </li></ul></ul></ul><ul><ul><ul><li>Out of hours? </li></ul></ul></ul><ul><li>Developing an Anticipatory Care Plan </li></ul>
    3. 4. The maze of trees
    4. 5. <ul><li>“ How we care for the dying must surely be an indicator of how we care for all our sick and vulnerable patients. Care of the dying is urgent care – with only one opportunity to get it right, to create a potential lasting memory for relatives and carers…” </li></ul>Professor Mike Richards CBE
    5. 6. ePCS - What is it? <ul><li>An electronic Palliative Care Summary </li></ul><ul><li>An extension to Emergency Care Summary (ECS) & </li></ul><ul><li>Gold Standards Framework Scotland (GSFS) </li></ul><ul><li>For use both In Hours & OOH </li></ul><ul><li>ePCS replaces current faxed communications </li></ul><ul><li>Allows GPs & Nurses to record in one place </li></ul><ul><li>Diagnosis, Rx, Pt Understanding & Wishes, Anticipatory Care Plans, review dates, lists for meetings </li></ul>
    6. 7. ePCS Overview GP /DN consultation OOH clinician ePCS display ePCS update 1. During consultation 2. Due to prescription 3. Team meeting or other contact Audit trail ECS Store NHS 24 A&E Ambulance TBD… Practice Admin. Staff
    7. 8. ePCS Dataset <ul><ul><li>Consent - Palliative care data transfer </li></ul></ul><ul><ul><li>Carer details and key professionals </li></ul></ul><ul><ul><li>Diagnosis – as agreed by patient by pt & GP </li></ul></ul><ul><ul><li>Current Rx –Rpt, 30/7 Acute, Allergies; </li></ul></ul><ul><ul><li>Patient wishes </li></ul></ul><ul><ul><ul><li>Preferred Place of Care [PPoC] </li></ul></ul></ul><ul><ul><ul><li>DNA CPR decision </li></ul></ul></ul><ul><ul><ul><li>Patient’s & Carer’s understanding of diagnosis/prognosis </li></ul></ul></ul><ul><ul><li>Just in Case – Rx & equipment </li></ul></ul><ul><ul><li>Advice for OOH care </li></ul></ul><ul><ul><ul><li>GP Mobile no., death expected? Cert. etc </li></ul></ul></ul>
    8. 9. EMIS - Summary
    9. 10. ePCS no diagnosis added yet
    10. 11. Diagnosis agreed with pt & added
    11. 12. Patient/Carer Wishes
    12. 13. New ECS build screenshots Access to PCS Information
    13. 14. Base ePCS –view in Adastra
    14. 15. Mobile ePCS - Adastra
    15. 16. Using ePCS in practice – a continuing process <ul><li>Does this pt have Palliative Care Needs? </li></ul><ul><li>Add to Pall Care Register, </li></ul><ul><li>Once Consents to send ePCS ->OOH, </li></ul><ul><li>agree Medical History, set review date </li></ul><ul><li>Once consented any new info goes automatically </li></ul><ul><li>Not expected to complete in one go! </li></ul><ul><li>Complete pt wishes and Understanding, DNA CPR, record “Just in case” Rx and Equipment as appropriate </li></ul><ul><li>Regular review at PHCT </li></ul><ul><li>Keep updating! </li></ul>
    16. 17. Profile of People who die <ul><li>UK1900 / </li></ul><ul><li>Age at death </li></ul><ul><li>46 </li></ul><ul><li>Top 3 causes </li></ul><ul><li>Infectious diseases </li></ul><ul><li>Accident </li></ul><ul><li>Childbirth </li></ul><ul><li>Disability before death </li></ul><ul><li>Not much </li></ul><ul><li>UK 2000 </li></ul><ul><li>Age at death </li></ul><ul><li>78 </li></ul><ul><li>Top 3 causes </li></ul><ul><li>Cancer </li></ul><ul><li>Organ failure </li></ul><ul><li>Frailty/ dementia </li></ul><ul><li>Disability before death </li></ul><ul><li>Months - many years </li></ul>
    17. 18. GP has 20 deaths per list of 2000 patients per year How to deliver End of Life care for all? Death High Low Many years Function Death High Low Months or years Function Organ failure 6 Acute 2 Dementia, frailty and decline 7 Death High Low Weeks, months, years Function 5 Cancer
    18. 19. Palliative Care DES (1 of 20!) <ul><li>1. Put pt on Palliative Care Register </li></ul><ul><ul><li>Clinical, Pt choice, Surprise Question </li></ul></ul><ul><ul><li>From Prognostic Indicator Guidance </li></ul></ul><ul><li>2. Send OOH form/ePCS within 2w </li></ul><ul><li>3. Make Anticipatory Care Plan – as ePCS </li></ul><ul><li>inc. Preferred Place of Care/death </li></ul><ul><li>4. When dying use LCP /locally agreed pathway </li></ul><ul><li>Aim- encourage anticipatory care, for all diagnoses </li></ul>
    19. 20. When will it be available? <ul><li>Pilots completed Aug 09 </li></ul><ul><ul><li>EMIS, Vision – Grampian, Gpass – A&A, Lothian </li></ul></ul><ul><li>Issues addressed included </li></ul><ul><ul><ul><li>acceptability & ease of use </li></ul></ul></ul><ul><ul><ul><li>improving the consultation & communication </li></ul></ul></ul><ul><ul><ul><li>anticipatory care planning, </li></ul></ul></ul><ul><li>NHS Lothian Rollout started Sep 09 </li></ul><ul><li>Evaluation by Edinburgh University </li></ul><ul><li>complete </li></ul><ul><li>National rollout in progress complete </li></ul><ul><li>early 2011 </li></ul><ul><li>Link with Board Leads for timings </li></ul><ul><ul><li>Palliative Care, eHealth,OOH </li></ul></ul>
    20. 21. ePCS – Summary <ul><li>Natural progression from GSFS & ECS </li></ul><ul><li>Fits into day to day work of GPs & DNs </li></ul><ul><li>Aims to identify patients “upstream” </li></ul><ul><li>ie last 6-12 months, not just last days/weeks </li></ul><ul><li>Encourages Anticipatory Care Planning </li></ul><ul><li>Prompts to remind to ask about “difficult” issues </li></ul><ul><ul><li>“ Just in Case”, DNA CPR, PPoC </li></ul></ul><ul><li>Shares critical info. on vulnerable patients at important times. </li></ul><ul><li>OOH & Secondary Care say it transforms care </li></ul><ul><li>Patients & carers reassured </li></ul><ul><li>Safer, better experience </li></ul>