Standard 2: Early identification - Example GP Practice Team EOLC group exercise

Record: Those attended, apologies, and date of meeting

The aim

  • To continuously develop a 'Supporting Care Register' for patients and carers affected by advanced serious illness, frailty and end of life care. 

Principles

  1. Named GP
  2. Patient's age
  3. Carer and people important to the patient, details
  4. Patient's capacity
  5. Legal documentation
  6. Diagnosis
  7. Inequality group
  8. Communication and information needs
  9. Patient's care and support needs
  10. Patient's preferences

Carer (NOK + Main Carer) - Consider, 'Who is the person who gives you the most help and support (who is not a healthcare professional)'

Discussion

The number on the Supportive Care Register should be maximised and early identification of patients is desirable. This should reflect the number of expected deaths that a practice would handle each year.

A simple formula to estimate this is:

 

Task

  1. For practice staff (clinical and non-clinical) to understand an agreed, clear protocol to identify patients and carers affected by advanced serious illness and end of life needs.
  2. Consider who at the practice is involved/has contact with patients and carers affected by advanced serious illness, frailty and/or end of life needs.
  3. Consider ALL staff opportunities for early identification, as part of their usual role. The majority of people are likely to be identified using common sense, robust processes and clinical judgment. There will be crossover between roles but some general examples are given below to stimulate discussion.
  4. Confirm how identified patients and carers will be collated and coded on a 'Supportive Care Register' (name of register can be decided by the practice).
  5. Confirm how identified patients and carers will be highlighted /flagged to ALL practice staff to enable rapid access.

Daffodil Standards rapid access to patients image 

Discuss the following questions as a group (and someone take notes on the key points)

  1. What happens currently to identify patients and carers early?
  2. What works well and what could be improved? Each person to discuss from their perspective. o Explore different people's attitudes, beliefs and experiences – ensure lone voices and concerns are heard.
  3. Each person (may help to group roles) to agree what they will commit to trialling within their role to support early identification.
  4. Set a timeline for the trial and for the review date.
  5. Review date to consider shared learning from trials, what happened, what worked well, what was less effective and what should be stopped (that is, it did not work), adapted or continued.
  6. Set next review date.

Informing part of the evidence on Standard 2

  1. Help create a protocol for identifying patients and carers, with ASI, frailty and EOLC needs
  2. Identify how to seamlessly code and record patients and carers onto the register
  3. Staff aware of the identification protocol, register and their role
  4. Components of the register known to all
  5. Share recording of percentage on list

Next: Standard 3: Carer Support >


QI 2: Continuous Improvement

  • Monthly recording of percentage of patients on practice list that is on Supportive Care Register. Displayed on a line graph, considering a number (or %) that is aligned with their population. Defined practice population (or %) = number of deaths in the last 12 months / total practice population

  • Monthly recording of percentage of carers for patients on Supportive Care Register. Displayed on a line graph with an increasing objective to reach around 60-90% of Supportive Care Register patients, or a % that is aligned with their population.

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