P-32 Improving outcomes for older people with frailty: shared decision making across community (care home) and hospital settings

Background

Post COVID-19 and with anticipated winter pressures, there was a clear need to ensure older people with frailty had timely assessments, with access to high quality end-of-life care and support.

Aim

To provide a rapid, coordinated response, to improve quality of care and decision making between patients, families and health care professionals across hospital and community settings and reduce hospital admissions from care homes (CH).

Methods

The CCG funded a dedicated rapid response end-of-life care team: 2 senior nurses (1.6 WTE), medical consultant (0.2 WTE) working alongside existing services. They coordinated inter-agency working through face-to-face and digital communication, prioritising face-to-face review and involvement of relatives. We trialled new approaches to triage requests for support and provided interventions in CHs including quick access to medications, fluids and/or diuretics.

Results

Over 11 weeks, 138 patients were assessed (mean age 88 ±7.5 years, 68% female). Half had diagnosed dementia, half had clinical frailty score of 8. Two thirds were in nursing homes. 39% were referred by their GP, 24% by the CH and 18% from hospital on discharge. 50% were seen face-to-face on the day of referral; 81% within a week. In 17.4% acute hospital conveyance was avoided by shared decision making between GP, LAS, CH staff and families. Treatment escalation plans were initiated for 56% and updated for a further 32%, including generation of shared electronic care plans. For 50%, single conversations with relatives were needed to support decision making; for a third this was more complex with multiple discussions over time. 36% died, with only 2 deaths in hospital. Whilst COVID affected 18 patients, only 2 of those died.

Conclusion

Flexible, integrated working enabled patients to receive care and die supported in their usual residence. Care homes need focussed resources and support to hold uncertainty in this disadvantaged group who traditionally don’t get access to specialist palliative care.