Thinking Outside The Square: Caring Inside The Home Gary Yip, Lucy - - PowerPoint PPT Presentation

▶
thinking outside the square caring inside the home
SMART_READER_LITE
LIVE PREVIEW

Thinking Outside The Square: Caring Inside The Home Gary Yip, Lucy - - PowerPoint PPT Presentation

Aug 01, 2023 96 likes •533 views

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

slide-1
SLIDE 1

Thinking Outside The Square: Caring Inside The Home

Gary Yip, Lucy Bassett, Jill Armstrong

22nd September 2017

Healthcare In A Person-Centred Era

slide-2
SLIDE 2

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
slide-3
SLIDE 3

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
slide-4
SLIDE 4

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.”

slide-5
SLIDE 5

The hospital

slide-6
SLIDE 6

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

slide-7
SLIDE 7

But there is a significant problem…

slide-8
SLIDE 8

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
  • 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

Frail

slide-9
SLIDE 9

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)
slide-10
SLIDE 10

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
slide-11
SLIDE 11

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.”

slide-12
SLIDE 12

The hospital

slide-13
SLIDE 13

The alternative

slide-14
SLIDE 14

Caring inside the home

  • Bringing “the hospital” to the patient!
  • How feasible is it?
  • RDNS
  • HITH
slide-15
SLIDE 15

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

slide-16
SLIDE 16

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.

slide-17
SLIDE 17

Redesigning the program

  • Using existing resources
  • “Complex Care in the Community”
slide-18
SLIDE 18

Complex Care – teams

Team leader (senior nurse) Deputy team leader (nurse / SW) GenMed physician GenMed physician GenMed physician GenMed pharmacist

slide-19
SLIDE 19

Complex Care – patient view

Team leader (senior nurse) GenMed physician GenMed pharmacist Patient Carer Outreach nurse Case manager Organ-specific physicians GP Outreach medical registrar Outreach physio & OT

slide-20
SLIDE 20

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

slide-21
SLIDE 21

Theory into practice

  • A case vignette
  • Mr Laurie Armstrong
  • 1927–2017
slide-22
SLIDE 22

Laurie

  • Enrolled in Complex Care program in November 2016
slide-23
SLIDE 23

Laurie

  • 89yo
  • Ischaemic heart disease – coronary artery bypass grafts
  • Cardiac arrest 1990
  • Biventricular failure
  • Atrial fibrillation
  • Chronic kidney disease (creatinine 290)
  • T2DM mild
slide-24
SLIDE 24

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
slide-25
SLIDE 25

To persist in hospital?

  • 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)

AT RISK YES YES AT RISK NO YES YES

slide-26
SLIDE 26

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
slide-27
SLIDE 27

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
slide-28
SLIDE 28

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
slide-29
SLIDE 29

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
slide-30
SLIDE 30

Complex Care – patient view

Team leader (senior nurse) GenMed physician GenMed pharmacist Laurie Jill Outreach nurse Case manager Organ-specific physicians GP Outreach medical registrar Outreach physio & OT

slide-31
SLIDE 31

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
slide-32
SLIDE 32

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
slide-33
SLIDE 33

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
slide-34
SLIDE 34

Progress at home

  • Reached 90th 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
slide-35
SLIDE 35

Progress at home

  • Reached 90th 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
slide-36
SLIDE 36

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!
slide-37
SLIDE 37

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
slide-38
SLIDE 38

Complex care – patient experience

  • Laurie’s words
  • Considerations around person-centredness
  • interactions with clinicians – active listening
  • taking in information, advice, instructions, action plans
  • ease of access to support
  • individualised care
  • feeling of self-control
  • staying out of hospital and nursing home
slide-39
SLIDE 39

Patient–carer dynamics

  • Sense of burden
  • Carer’s wellbeing
slide-40
SLIDE 40

Kindness is a universal language

slide-41
SLIDE 41
slide-42
SLIDE 42

Kindness is a universal language

  • Applying it in clinical practice
  • start by putting yourself in the patient’s shoes
  • ask, listen to, and respect what the patient’s values are
  • decide individualised goals of care
  • avoid diminishing patient’s sense of control