Ambulance
           EMAS
                                                   Compassionate
        Hospic                                       Community
                                           Respec     Churches etc
           es                EEPPaaCCCCSS  Respec
                                              t
           x3                                 t
      370 Care                                           OOH/1
       homes                                               11
                                                         NEMS
                                Care                  Patient 
                             Co-ordination          Indentification
                               Service               Strategy
    Key Performance Indicators – Measuring Quality
                                         Please note the KPI’s are to be finalised to ensure the most effective measures are 
    Current service provision                                included in the model 
    •   Non-dependent KPI’s across 5 contracts 
    •   KPI’s Do not reflect the whole patient pathway – acute care, social care, third sector, making baseline data analysis redundant 
    •   No coordination of KPI’s leading to possible duplication of service
    •   Currently 27% of patient in the last year of life will present at ED
    •   Currently 0.4% of the total population is registered on EPaCCS
    •   1111 Patients in Mid-Notts died in an acute setting which is 66% of all deaths.
    Proposed KPI’s – central data source from EPaCCS 
    KPI                                                       Threshold
     % of deaths in preferred place of care                   A 5% annual increase in the number of end of life care 
                                                              patients that die in their place of choice or usual place 
                                                              of residence (Year 1)
    Number of patients with written advance care plan or      Year one – establish a baseline for all patients with an 
    evidence that an advance care plan discussion has been  advance care plan
    offered
                                                              Annual % increase until 90% of all patients on the end 
                                                              of life care register have been offered an advance care 
                                                              plan
    Increase number of patients identified on EPaCCS          0.7% of all patients in year one and continue to 
    Patient Identification                                    maintain
    Reduction of unnecessary ED  attendances to hospital      Year one – establish a baseline followed by an agreed 
    for patients at End of Life                               annual % increase
    Additional PROMS evaluations will be undertaken to        ReSPECT, Patient and Public inclusivity and equity, 
    improve quality to include:                               bereavement support and patient quality
     Compliance with KPI’s
                                        6.0
                                        4.5
                                        3.0
                                        1.5
                                        0.0
                                                          % EPaCCS pts attending ED                Plan
                                      8.0
                                      6.0
                                      4.0
                                      2.0
                                      0.0
                                                   %+KPI!$1:$1 of EPaCCS pts attending ED            Plan
  Key Performance Indicators
 Increase of patients registered on EPaCCS: 2127 patients are registered on EPaCCS 
 Increase in the number of patients with an Advance Care Plan:  of the 2127 patients 
 on EPaCCS 1208 have an advance care plan
 Increase in the number of patients who achieve their preferred place of death: 
 Patients with preferred place of care recorded 82% of patients achieved their 
 preferred place of care
 Reduction in the number of deaths within four days of admission:    
 Reduction in ED attendances:  585 less attendances from October 2018 to April 2019, 
 compared to compared to baseline period
 Reduction in Hospital Admission following ED attendance: 288 less admissions from 
 October 2018 to April 2019 compared to baseline period
                                             Summary of Notts ICS EOL Workstream
       Themes and activities in WORKSTREAM (Priorities)                                                                                                               Enablers and 
                                                                                                                                                                      interdependencies 
       1                                                                                                                                                          ▪ Workforce: recruit, inspire, 
       Identification of              1    Implement an identification strategy targeting commonly missed groups (e.g. learning disabilities, dementia,              retain resilient skilled 
       patients likely to be in            non-malignant long term conditions) and incorporating all relevant organisations including care homes and                 professionals.
       their last 12 months of             community groups Gold Standards Prognostic Indicator Guidance
       life                            2   Initiatives to promote public discussion of dying, death and bereavement to empower the public to identify their 
                                           own needs and those of each other. e.g. Dying matters week, Death Cafes etc. https://www.dyingmatters.org/             ▪ IM&T: Ongoing resources 
                                                                                                                                                                     required and analysis of 
                                           All patients have the opportunity to complete an advance care plan (ACP) http://endoflifecareambitions.org.uk/            data available to feedback 
                                      3    a)Dementia patients should be supported to start an ACP within a year of diagnosis                                        activity to organisations on a 
                                           b)Those with learning disabilities should be supported to make detailed advance care plans which may require              local level
      2                                    best interest decisions multidisciplinary meetings to ensure full MCA compliance
       Care of the Patient             4    Roll out the ReSPECT process www.respectprocess.org.uk/                                                               ▪ Estates: 
       Personalised care plan               A robust sustainable long term strategy for developing IT to facilitate sharing of plans.  All organisations should 
       Holistic Symptom                     be able to access the most recent version of the plan when they need to.  Individuals should have easy                ▪ Mental health: long waits 
       control                        5     access to their own plans. http://endoflifecareambitions.org.uk/                                                         for psychological support, 
       Communication                        http://www.endoflifecare-intelligence.org.uk/view?rid=787                                                                poor access for those who 
       Care co-ordination                   Develop a care co-ordination service, directly accessible by patients, carer and professionals.  Accessible to           are housebound.  
                                       6    all identified patients 24/7.  This should reduce inappropriate interventions and release resources to increase 
                                            capacity http://endoflifecareambitions.org.uk                                                                         ▪ Prevention:
                                            Strategy to improve pain control in the home. All patients should have prompt access to measures to 
                                       7    effectively control pain and distressing symptoms. Hospice UK No Painful Compromise                                   ▪ Organisations
                                            https://www.nice.org.uk/guidance/ng31                                                                                    – Out of Hours
                                            Specialist palliative care should be available 24/7 for those with more complex needs.                                   – 111
                                            Develop a framework for education, training and continuing professional development                                      – EMAS
                                       8    http://endoflifecareambitions.org.uk    http://www.goldstandardsframework.org.uk/training-programmes                     – Social Care
      3                                     End of Life Care educational support to primary care, secondary care and community health care teams  
                                                                                                                                                                           rd
      Support those                                                                                                                                                  – 3  Sector Services
                                      9     Identify carers and undertake a carer’s care plan to ensure their needs are met                                             Integrated, collaborative 
      important to the dying 
      person                                http://www.ncpc.org.uk/sites/default/files/Who_Cares_Conference_Report.pdf                                            relationships required
      Regular support                 10   Increase capacity for care at times and in places that are currently under-capacity.  To ensure black and              ▪ Community partnerships
      Respite                              minority ethnic communities, those in deprived areas, the homeless and imprisoned have equal access to care.              – Patient groups
      Bereavement Care                     http://endoflifecareambitions.org.uk   Enable integrated working via suitable contract that mandate this                  – Faith/cultural groups
                                      11
                                           Ensure carers are aware of how to access psychological support (pre-bereavement and bereavement care).  
                                           Develop a ‘Listening Service’ within practices to increase front line access
                                      12
                                            Commission resources/services to promote patient and carer self care
       Each person is seen as an           Each person gets fair          Maximising comfort and                                         All staff are prepared         Each community is 
                                                                                                          Care is coordinated                    to care                 prepared to help
               individual                      access to care                     wellbeing