Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Microsoft PowerPoint - Janice Brown [Compatibility Mode]

2,418 views

Published on

  • Be the first to comment

  • Be the first to like this

Microsoft PowerPoint - Janice Brown [Compatibility Mode]

  1. 1. Piecing it Together: A Pathway to Encourage y g Partnership Working Dr Janice Brown University of Southampton Partnership team: Lucy Sutton, National Policy Lead, NCPC Neurological Conditions Policy Group, UK MND Professional Network, , Consultation participants, Pilot site participants.
  2. 2. Why do we need a pathway? • Neurological care is complex: many symptoms and disabilities across variable timeframes • Patients may need consideration of early referral to palliative care and/or rehabilitation services • Care for neurological illness spans many disciplines: neurology, rehabilitation, palliative care, social services and voluntary agencies • Each contributing speciality has much expertise to offer • Need to ensure services do not duplicate themselves but work together and provide coordinated care through the disease trajectory
  3. 3. What is a pathway? • A means to improve delivery of care to patients and families • A multidisciplinary t l t d t il essential steps and ltidi i li tool to detail ti l t d decisions in the care of patients with specific clinical problems • A resource for promoting appropriate, timely referrals • A resource to enhance partnership working, promote communication and encourage seamless transitions g between services • A template suitable for adaptation to local need
  4. 4. Aims of the pathway • To support continuing improvement in quality of care for people with palliative care needs from neurological conditions g • To enhance the interface (partnership working) between pivotal services: neurology, palliative care neurology care, rehabilitation, social care, voluntary agencies • To use in-built triggers, questions to prompt consideration of palliative care across the patient journey
  5. 5. Developing the Pathway 1. Review of the evidence 2. Consultation process 3. The pathway in practice: Pilot sites
  6. 6. 1. Review of the evidence - examples • Policy • NSF Long-term conditions • Continuing care assessment • Guidelines • G ld St d d F Gold Standards Framework k • NICE guidelines • Liverpool care pathway • Research • Plumb (2006) • Edmonds et al (2005) • Rossiter & Thompson (1995)
  7. 7. 2. 2 Consultation process • National NCPC events (240 participants) • Neurological conditions policy group • Web site www.ncpc.org • NCPC j journals and neurological group l d l i l publications
  8. 8. 3. The pathway in practice: Pilot Sites Six initial il t it Si i iti l pilot sites: neurology, rehabilitation, palliative l h bilit ti lli ti care, Sue Ryder neurological centre, x2 MND Association care centres Initial findings: • supportive tool for practice, comprehensive practice • pathway template detailed but adjustable for local use • promoting of inter-professional practice and inter professional communication • useful for triggering referrals and forward care planning • reduces risk of patients slipping th d i k f ti t li i through th referral net h the f l t • supportive tool for education of health and social care p professionals
  9. 9. Structure of the Pathway St t f th P th PATHWAY 1 Pathway to Neurological Diagnosis g PATHWAY 2 Neurological Pathway (2 parts) 2i) At diagnosis and early action considerations 2ii) Neurological pathway
  10. 10. Pathway 1 Pathway to Neurological y g Neurological Symptoms Diagnosis G.P. Other specialists – ENT, rheumatologist, Consultant Neurologist gerontologist, ophthalmologist, psychiatrist, psychiatrist neurosurgeon In-patient investigations: 2nd opinion EMG, MRI, Bloods, CSF…… Preparing to tell the diagnosis: Have you i) A specialist nurse ready to be present? ii) Asked for a relative to be present? Telling the diagnosis/ iii) A 2 week repeat appoint to offer with consultant/sp nurse? Inform providing information/ iv) Voluntary agency details to give out - e.g MND Association GP & DN offering treatment v) Local guidelines on telling diagnosis? & vi) Identified initial key worker or single point of access to Specialist services for case management? Nurse. Nurse Liaise with hospital Have you made: team i) 2/52 repeat appoint with consultant/specialist nurse? Go to the NCPC ii) Follow-up Follow up consultant clinic NEUROLOGICAL CARE appt for 3/12? PATHWAY 2 Brown & Sutton 2007
  11. 11. Considerations • Neurological conditions vary in presentation but often there are parallels with symptoms and need for services • It is very difficult to make some diagnoses: may require a time period for further observation, may require a second opinion y q p • In these pathways we are talking about ideals, recognising that local services may be limited in what can be offered
  12. 12. Structure of Pathway Two Part 1 Early action considerations Part P t2 Neurological C N l i l Care P th Pathway *Indicators f Referral *I di t for R f l **Attention to Policy Neurological care pathway
  13. 13. Pathway 2 Part 1: At Diagnosis - Early Action Considerations Would you be At Point of Diagnosis surprised if patient was not alive in 6-12 months? 6 12 No Inform GP & Would you be DN & surprised if Specialist Discuss Advance patient could nurse in Care Plan/ not hospital: liaise Decisions & communicate YES with hospital consider Gold in 6 months? Standards Framework Identify key worker or single point of contact for case Consider Referral to Specialist Consider referral to Neuro – management Palliative Care Palliative Rehabilitation Indicators for referrals/decisions Brown & Sutton 2007
  14. 14. What is neuro-palliative rehabilitation? Holistic, patient centred approach to the care of neurological patients with significant di bilit l i l ti t ith i ifi t disability, complex needs and a potentially shortened life span. Includes diagnosis of clinical problems, rehabilitation to maintain function, care , coordination and appropriate palliation to relieve symptoms. y p
  15. 15. Pathway 2 Part 2* Indicators for referral Indicators for referrals/decisions Breathlessness Swallowing Communication Cognitive Mobility Social issues issues difficulties issues issues difficulties with eating & drinking, poor nutritional status Medical Emotional complications issues Financial/ Housing: Input from co-ordinated (by KW) multi-professional team, SALT, OT, Impaired Employment dietician, physio, neuropsychiatry, mental health services, voluntary agencies, ability Input from co- and/or genetic counselling, community therapists, continence, pain to make ordinated Family decisions? rehabilitation team, issues: p y , physio, OT, wheelchair , Input from services, motability, social team: Consider PEG Consider active management: environmental care feeding tube Yes antibiotic & assisted ventilation controllers, manager, Life spasticity clinic grants team, Yes expectancy benefits Patient wants active management? adviser, Vol , predicted Psychologist, Psychologist < 6-12 months No religious leader, agencies Symptom/ counselling teams No, not sure comfort Refer to appropriate management Advance care plan/Decision acute services Advance care plan/decisions for Consider Advice from and Linking Consider referral to Neuro- Palliative future management with Palliative Care Rehabilitation Brown & Sutton 2007
  16. 16. Pathway 2 Part 2** Indicators for referral & attention to policy Indicators for referrals/decisions Consider Breathle Swallowing Communication Cognitive Mobility Social 18 ssness issues issues difficulties issues issues Week difficulties with eating Delivery & drinking, poor nutritional status Medical Emotional Quality complications issues Financial/ Of life Housing: Input from co-ordinated (by KW) multi-professional team, SALT, Impaired Employment OT, dietician, physio, neuropsychiatry, mental health services, voluntary ability Input from co- and /or Patient agencies, genetic counselling, community therapists, continence, pain to make ordinated Family Choice decisions? rehabilitation team, issues: p y , physio, OT, wheelchair , Input from Consider active m’ment: services, motability, social team: Consider PEG Preferred antibiotic & assisted environmental care feeding tube Yes Place of ventilation controllers, manager, Care Life spasticity clinic grants team, Yes expectancy benefits Patient wants active management? adviser, Vol , predicted Psychologist, Psychologist Comfort < 6-12 months No religious leader, agencies Symptom/ counselling teams No, not sure comfort Refer to appropriate Cont management Advance care plan/Decision acute services Care Advance care Assess- plan/decisions for Consider Advice from and Linking Consider referral to Neuro- Palliative ment future management with Palliative Care Rehabilitation Brown & Sutton 2007
  17. 17. At Point of Diagnosis Would you be surprised if patient was not No alive in 6-12 Inform GP & DN & Would you be Specialist nurse in surprised if months? hospital: liaise with Discuss Advance Care patient could hospital team Plan/Decisions not NEUROLOGICAL communicate YES & consider Gold Standards in 6 months? CARE PATHWAY Identify key worker Framework or single point of contact for case management Consider Referral to Specialist Palliative Care Consider referral to Neuro – Palliative Rehabilitation Consider: C id Indicators for referrals/decisions 18 Week Delivery Communication Cognitive Swallowing issues Mobility issues Social Breathlessness issues difficulties difficulties with eating issues Q Quality y & drinking, poor drinking Of life Medical nutritional status Emotional complications Impaired issues Financial, ability housing; Patient Input from co-ordinated (by KW) multi-professional team, SALT, to make Input from co-ordinated employment Choice OT,dietician, physio, neuropsychiatry, mental health services, voluntary decisions? rehabilitation team, and/or agencies, agencies genetic counselling, community therapists, continence pain counselling therapists continence, physio, OT, wheelchair Family services, motability, issues: Preferred Consider active management: Consider Yes environmental controllers, Input from Place of antibiotic & assisted ventilation PEG Life spasticity clinic social team: Care feeding tube expectancy care predicted manager, manager Patient wants active management? Yes < 6-12 months Psychologist, grants team, Comfort No benefits Symptom/ religious leader, No, not sure counselling teams adviser, Vol comfort Refer to appropriate agencies Cont management Care acute service Advance care plan/Decision Advance care Assess- plan/decisions for ment future management Consider Advice from and Linking Consider referral to Neuro- Palliative with Palliative Care Rehabilitation Brown & Sutton 2007
  18. 18. Conclusions The Pathway A national template for neurological care g Initial Pilot Work Supportive of the value of the pathway for achieving its aims NCPC Specialist nurse survey 83% useful for their practice Dissemination Conferences: International and European Pathway published and accessible for use and/or local adaptation NCPC [2007] Focus on Neurology website www.ncpc.org.uk The Future Assess its impact on care of people with neurological conditions
  19. 19. A Pathway to Encourage Partnership Working Dr Janice Brown University of Southampton Partnership team: Lucy Sutton, National Policy Lead, NCPC Neurological Conditions Policy Group, UK MND Professional Network, Consultation participants participants, Pilot site participants.

×