Healthcare In A Person-Centred Era Thinking Outside The Square: Caring Inside The Home Gary Yip, Lucy Bassett, Jill Armstrong 22nd September 2017
Setting the scene • Elderly • “Declining health”, “becoming more vulnerable” • Emphysema, heart failure, kidney disease, diabetes, arthritis • Cognitive decline, visual impairment • Muscle wasting, gait imbalance • Waning immune defences • On myriad medications • Short of breath, fatigued, dizzy, joint pains • Falls, reduced appetite, fragmented sleep • Recurrent infections, chronic wounds • Existential: identity, connectedness, sense of control, joy
Common denominator • Lots of interaction with healthcare system and health professionals • Day-to-day maintenance • GP, local pharmacy, district nurses, physiotherapy centre • Monitoring of medical conditions • Specialist physicians (hospital outpatients or private rooms) • Unwell (eg. pneumonia, fall, flare of heart failure, dehydration) • Emergency department and hospital admission
The hospital • “Hospitals are health care institutions that have an organised medical and other professional staff, and deliver services 24 hours per day, 7 days per week.”
The hospital
The hospital • “Hospitals are health care institutions that have an organised medical and other professional staff, and deliver services 24 hours per day, 7 days per week.” • Is perceived as the best option for seeking help during times of health instability
But there is a significant problem…
Those we care for • Elderly • “Declining health”, “becoming more vulnerable” • Emphysema, heart failure, kidney disease, diabetes, arthritis • Cognitive decline, visual impairment • Muscle wasting, gait imbalance Frail • Waning immune defences • On myriad medications • Short of breath, fatigued, dizzy, joint pains • Falls, reduced appetite, fragmented sleep • Recurrent infections, chronic wounds • Existential: identity, connectedness, sense of control, joy
But there is a significant problem… • Frail persons in hospitals • Hospital-acquired infections • Physical de-conditioning • Skin breakdown • Disorientation – falls, delirium • Pain • Less appetite (limited dietary options) • Less sleep (unfamiliar bed, noise)
But there is a significant problem… • Even more importantly, the spiritual aspects • Deprivation of mental stimulation • Loss of control • Lonely • Frightening (other events on the ward) • Uncomfortable (sitting by the bed all day) • toilet, shower • Loss of dignity • clothes, lack of privacy • Erosion of precious time
The hospital • “Hospitals need to be organised around people’s needs, working closely with other health and social care services and contributing to strengthening primary health care, to substantially contribute to Universal Health Coverage.”
The hospital
The alternative
Caring inside the home • Bringing “the hospital” to the patient! • How feasible is it? • RDNS • HITH
Shifting the paradigm • Defining our core mission • Person-centred care • keeping hospital admissions to an absolute minimum • Two key components • patients and carers who can detect health deterioration at an early stage • a health professionals team that is highly responsive to unplanned needs
Shifting the paradigm • RDNS • narrow scope (specific tasks), limited responsiveness, blurred medical governance • HITH • narrow scope (restricted conditions), patient generally needs to be in hospital to begin with, short-term involvement • Buurtzorg model – Netherlands • “championing humanity over bureaucracy” Monsen K et al. Creative Nursing 2013. 19(3):122–7.
Redesigning the program • Using existing resources • “Complex Care in the Community”
Complex Care – teams Team leader Deputy team leader (senior nurse) (nurse / SW) GenMed GenMed physician pharmacist GenMed GenMed physician physician
Complex Care – patient view Team leader GenMed (senior nurse) physician GenMed Outreach nurse pharmacist Patient Carer Outreach Organ-specific medical physicians registrar GP Case Outreach physio & manager OT
Essential capabilities • Two key components • patients and carers who can detect health deterioration at an early stage • a health professionals team that is highly responsive to unplanned needs • Education, counselling, reinforcement, surveillance • team leader, outreach nurse, GenMed physician • Responding to health deterioration • team leader, outreach nurse, case manager, outreach medical registrar, GenMed physician
Theory into practice • A case vignette • Mr Laurie Armstrong • 1927–2017
Laurie • Enrolled in Complex Care program in November 2016
Laurie • 89yo • Ischaemic heart disease – coronary artery bypass grafts • Cardiac arrest 1990 • Biventricular failure • Atrial fibrillation • Chronic kidney disease (creatinine 290) • T2DM mild
Index hospital admission • October 2016 • Over preceding eight months, had gained 13kg (predominantly peripheral oedema in legs, but also bilateral pleural effusions) • Two-monthly outpatient specialist reviews, with slight adjustments to diuretic doses • Admitted directly from outpatient clinic • But after 12 days in hospital, had lost only 4kg
To persist in hospital? • Frail persons in hospitals AT RISK • Hospital-acquired infections YES • Physical de-conditioning YES • Skin breakdown AT RISK • Disorientation – falls, delirium NO • Pain YES • Less appetite (limited dietary options) YES • Less sleep (unfamiliar bed, noise)
To persist in hospital? • Being mindful of the spiritual aspects • Deprivation of mental stimulation • Loss of control • Lonely • Frightening (other events on the ward) • Uncomfortable (sitting by the bed all day) • toilet, shower • Loss of dignity • clothes, lack of privacy • Erosion of precious time
Decision • Allow Laurie to leave hospital • Implement Complex Care team around Laurie • ensuring Jill was also an active member of the team • Receive ongoing care in own home • Remember, still 9kg above baseline • Creatinine 335 • Frusemide 500 – 250 – 250 mg • Hydrochlorothiazide 12.5 mg bd
Caring inside the home • How feasible is it? • What premium is placed on it? • access to normal routines, independence • control • comfort and company • dignity and privacy
Caring inside the home • How feasible is it? • All members of Complex Care team need to be comfortable, confident and committed • Conversation with patient and spouse, to establish • patient’s perspective on their current trajectory • alignment of goals of treatment – quality and quantity • ability of patient to carry out certain actions when at home • capacity of spouse to play a critical role
Complex Care – patient view Team leader GenMed (senior nurse) physician GenMed Outreach nurse pharmacist Laurie Jill Outreach Organ-specific medical physicians registrar GP Case Outreach physio & manager OT
Essential capabilities of the clinical team • Belief system and motivation: stay out of hospital at all cost • Problem solving and lateral thinking (‘outside the square’) • capitalising on everyone’s own lens • Risk appetite (mutual) • articulate honestly, frequently, and ahead of time • Intense work: invested in individuals • Reflection and experiential learning
Essential capabilities of patient / carer • Engaged and activated patient • Committed and available carer • Processing and absorbing new information • Not afraid to initiate contact with clinicians
Progress at home • Compression stockings plus high-dose diuretics • Lost 9kg over two weeks • Proactive contact by team leader (senior nurse) • three times per week • Promote sustained interest and embedded routine • “Checking-in” home visits • Maintenance phase – action plan • Knowing when advice is needed – empowerment
Progress at home • Reached 90 th birthday in April 2017 • One hospital admission shortly thereafter • creatinine 500 • Community palliative care services arranged • to augment Complex Care team • advance planning towards dying at home
Progress at home • Reached 90 th birthday in April 2017 • One hospital admission shortly thereafter • creatinine 500 • Community palliative care services arranged • to augment Complex Care team • advance planning towards dying at home • Further hospital admission after collapsing • passed away in June 2017
Outcomes • Eight months of Complex Care • Total of six days in hospital during those eight months • Optimal sense of control and dignity • All the stars aligned!
Complex care – quality teamwork • Respect and growing trust • Leadership • Minimise hierarchy and craft group boundaries • Know each other’s strengths and blindspots • Openness and honesty • Pre-empt stress • Celebrate successes • Discuss regrets and areas for improvement (supportively) • Communication – permission to share all types of experiences • Employ technology • Being available
Recommend
More recommend
