A group of CCGs in Sussex, working together as Sussex NHS Commissioners, have introduced a clinically-led collaborative approach for better care planning and coordinating of patient care near the end of life. The partnership approach with clinicians, health care professionals and industry, supports early information sharing and embeds joint-working between general practice, hospices, specialist palliative care and community-based services. The team developed a process to deliver a proactive care model, rather than a reactive one. Using and adapting our ARTEMUS Risk Profiling digital solution, they were able to allow early identification of those reaching end-of-life (EoL) and who might benefit from earlier support to plan their care.
The project was awarded ‘Highly Commended’ in the 2020 HSJ Value Awards in the IT and Digital Innovation Category.
NHS West Sussex CCG’s Head of Integration, Jacqui Nettleton says: “We believe we have delivered an innovative digital solution to identify people early in their end of life pathway and maximised on the benefits that earlier intervention should deliver for the health economy, patients, their families and carers.”
Key results
This new way of working has improved patient care and the patient experience, as well as producing significant savings by reducing the cost of hospital care by decreasing the number of deaths in hospital, reducing A&E attendances and non-elective admissions. COVID-19 has demonstrated how important it is to plan at an individual level and population level for EoL care.
Key issues in EoL care
Nationally there is an average of three unplanned hospital admissions in the last six months of a patient’s life, and primary and community based EoL care can be fractured and reactive, with care planning often ad hoc and frequently in response to crises. There is also limited access to palliative care and for those who are frail and have long term conditions it is often restricted to the terminal phase and focusses almost exclusively on people with cancer.
It is clinically difficult to identify people who are in the last six to 12 months of life particularity for those with progressive long-term conditions and there is a lack of validated tools to support clinical decision making. However, if initiated earlier, palliative care can have a significant impact on patient experience.
The ‘Planning Your Care’ pilot in Crawley
The team at Crawley wanted to deliver a proactive EoL and palliative care pathway to involve multi-disciplinary teams across primary care, community care and palliative care. The team modified their existing risk stratification tool, ARTEMUS, to identify palliative patients in an earlier phase of their disease trajectory, by applying an EoL algorithm to inform case finding. They then implemented a structured process to triage and proactively plan care in GP practices.
The team wanted to increase the number of patients on the palliative care register with non-malignant disease receiving specialist palliative care. They also wanted to increase the number of patients with a care plan recorded and reduce the number of patients dying in hospital and increase the number of patients dying in their place of preference or usual place of residence, while improving the quality of care for patients at end of life allowing them to have a good death.
Work started with a pilot across four practices with a total population of 30,306, which ran for 10 months. The project reviewed 299 patients, which equates to approximately 10% of the pilot population. There were 200 patients on the caseload (0.65% of pilot population) and 27 deaths from the Planning Your Care (PYC) Caseload (0.09% of pilot population). The oldest patient on the caseload was 99 and the youngest 48. Based on the ARTEMUS risk stratification tool 46% of these had a risk of admission below 50%. Patients have an Efrailty risk score ranging 0.56 to 0.03.
Patients have had between one and 14 Long Term Conditions; heart failure and frailty are the most common.
Implementing the solution
The team used our ARTEMUS Risk Profiling tool and worked together to extend its functionality. By amalgamating data sets and using a new set of algorithms which are based on other predictive tools they would be able to identify those patients, including: the Charleston co-morbidity score, CriSTAL, SPICT, measurable clinical features of organ and neurological functional deterioration and commonly used frailty indicators. By using a correlation of integrated data sets it can simplify decision making for EoL and become a precursor to clinical decision making.
These factors together provided early indicators for those in the last 12 months of their EoL journey.
ARTEMUS EoL provides quick access to multiple factors which can be viewed at a glance to provide greater insight on the patient.
Greater insight on patient level data
At a glance, multiple factors provide greater insight on the patient level data. Users can now view risk of admission score, frailty score and comorbidity index, along with a number of deteriorating factors plus number of A&E attendances and admissions and whether care processes assigned or not in a continuum.
Positive Outcomes
The improved proactive care co-ordination and planning process was underpinned by developing and embedding it within the GP IT Systems and the National ReSPECT care plan.
The team increased the numbers of patients with a care plan and the number of those on the palliative care register; improved different aspects of the quality of the remaining life of patients with non-malignant disease; and involved patients and their carers in the care planning process at an earlier stage.
The tool has improved care co-ordination and patient choice care planning, while also identifying clinically appropriate GP practice patients for EoL care.
