Mark Cobb

Barriers to providing palliative care for older people in acute hospitals

BACKGROUND the need for access to high-quality palliative care at the end of life is becoming of increasing public health concern. The majority of deaths in the UK occur in acute hospitals, and older people are particularly likely to die in this setting. However, little is known about the barriers to palliative care provision for older people within acute hospitals. OBJECTIVE to explore the perspectives of health professionals regarding barriers to optimal palliative care for older people in acute hospitals. METHODS fifty-eight health professionals participated in eight focus groups and four semi-structured interviews. RESULTS participants identified various barriers to palliative care provision for older people, including attitudinal differences to the care of older people, a focus on curative treatments within hospitals and a lack of resources. Participants also reported differing understandings of whose responsibility it was to provide palliative care for older people, and uncertainly over the roles of specialist and generalist palliative care providers in acute hospitals. CONCLUSIONS numerous barriers exist to the provision of high-quality palliative care for older people within acute hospital settings. Additional research is now required to further explore age-related issues contributing to poor access to palliative care.

Extent of palliative care need in the acute hospital setting: A survey of two acute hospitals in the UK:

Background: In common with international health policy, The End of Life Care Strategy for England has highlighted the delivery of high quality palliative care in the acute hospital setting as an area of priority. Aim: The aim of this study was to explore the extent of palliative care need in the acute hospital setting, and to explore agreement between different sources in the identification of patients with palliative care need. Design: A cross-sectional survey of palliative care need was undertaken in two UK acute hospitals. Hospital case notes were examined for evidence of palliative care need according to Gold Standards Framework (GSF) prognostic indicator criteria. Medical and nursing staff were asked to identify patients with palliative care needs. Patients (or consultees) completed assessments of palliative care need. Participants: Of a total in-patient population of 1359, complete datasets were collected for 514 patients/consultees. Results: 36.0% of patients were identified as having palliative care needs according to GSF criteria. Medical staff identified 15.5% of patients as having palliative care needs, and nursing staff 17.4% of patients. Patient self-report data indicated that 83.2% of patients meeting GSF criteria had palliative care needs. Conclusion: The results reveal that according to the GSF prognostic guide, over a third of hospital in-patients meet the criteria for palliative care need. Consensus between medical staff, nursing staff and the GSF was poor regarding the identification of patients with palliative care needs. This has significant implications for patient care, and draws into question the utility of the GSF in the hospital setting.

What Can We Learn About the Spiritual Needs of Palliative Care Patients From the Research Literature

CONTEXT Spirituality is a distinctive subject within palliative care practice and literature, but research to date is relatively undeveloped in this field and studies often throw more light on conceptual and methodological issues than producing reliable data for clinical practice. OBJECTIVES To determine what is known about the spiritual needs of palliative care patients from the evidence presented in published research. METHODS Specialist online databases were interrogated for primary empirical studies of patients with a chronic disease unresponsive to curative treatment. Studies that only used a proxy for the patient or reported expert opinion were excluded. Each study was critically appraised for quality and the strength of its evidence to determine if any data could be pooled. RESULTS Thirty-five studies were identified, equating to a total of 1374 patients. Study populations were typically people with advanced-stage cancer, older than 60 years, who were English speaking, and with a Christian or Jewish religious affiliation, reflecting the predominance of Anglo-American studies. Studies fell into two groups: those that investigated the nature of spiritual experience and those that examined the relationship of spirituality with other phenomena. The evidence was insufficiently homogeneous to pool. CONCLUSION Relevant accounts of what spirituality means for palliative care patients and evidence of how it operates in the lives of people with life-limiting disease can be derived from research. Studies to date are limited by reductive representations of spirituality and the conduct of research by health professionals within health care communities demarcated from disciplines and interpretive traditions of spirituality.

A prospective study of the roles, responsibilities and stresses of chaplains working within a hospice

Spiritual care is an integral part of palliative care and if asked, most members of a palliative care team would state they address spiritual issues. The majority of hospices have support from a chaplain. This study was to determine the roles of chaplains within hospices and to look at their levels of stress. A questionnaire containing both open and closed questions was sent to chaplains working within hospices in the UK. The questionnaire enquired about number of sessions, specific roles of chaplain, whether they were members of the multidisciplinary team and their sources of internal support. Stress was measured on a 10-point Likert scale and the GHQ12. One hundred and fifteen questionnaires were returned, with a 72% response rate. The majority (62%) defined their denomination as Church of England and Free Church (24%); 71% of respondents had parish commitments in addition to their hospice role. Roles were predominantly defined as spiritual care of patients and staff (95%) and bereavement support of relatives (76%) and 75% regularly attended the multidisciplinary meetings. Senior medical and nursing staff and other chaplains were perceived as providing most support. Median Likert score for stressfulness was 5, and 23% scored at or above the threshold on the GHQ12 for identifiable psychological morbidity. Clear role definition was associated with less perceived stress whereas the provision of bereavement support was associated with statistically significant increased perceived stress. The role of a chaplain within a hospice is varied and this study suggests that the provision of training and formal support is to be recommended.

Outcomes for Professional Health Care Chaplaincy: An International Call to Action

Health care in industrialized countries is increasingly focused on outcomes (Department of Health, 2013). The reasons for this focus are complex and contextualized but adopting this new currency is a central driver in each of the health care systems in the countries we represent (Australia, Canada, England, Scotland, and the United States). Primary to this focus is the recognition that the cost of health care as currently provided is unsustainable. The funding of interventions and care providers is increasingly evaluated against the data for the efficacy of the intervention; that is, does it serve one or more valued outcomes? Valued outcomes are generally those that reduce costs, improve the quality of care and patient experience often measured by patient satisfaction, and=or enhance health outcomes often measured by cure rates, reduced lengths of stay, or reduced use of health care resources (Berwick, Nolan, & Wittington, 2008). There is increasing evidence that patient experience contributes along with patient safety and clinical effectiveness in influencing outcomes (Doyle, Lennox, & Bell, 2013). Whereas chaplains have generally been exempt from this economic focus, increasingly the value of chaplaincy care is being evaluated on these criteria. A common conceptualization resulting from this shift is ‘‘volume to value’’ (Porter & Teisburg, 2006). Thus, outcome measures that can be determined to contribute value are preferred over the number of patient contacts. The issue is howmuch value a health care individual or an intervention adds to the system. Michael Porter at Harvard Business School has defined value as quality divided by cost (Porter & Teisberg). Concurrently, there has been increased focus on moving the person to the center of care and thereby differentiating between clinical and personal outcomes. Clinical outcomes are what a clinician wants for the patient often through a medical lens as opposed to personal outcomes which are what a person wants=desires for themselves in terms of function= way of being following a health care intervention. Such a person-centered approach focuses on the assets, capacity and resilience of individuals and takes into consideration their natural support systems, including community based resources. It involves working toward co-production of well-being rather than Journal of Health Care Chaplaincy, 20:43–53, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 0885-4726 print=1528-6916 online DOI: 10.1080/08854726.2014.902713

What is the extent of potentially avoidable admissions amongst hospital inpatients with palliative care needs

BackgroundThere is clear evidence that the full range of services required to support people dying at home are far from being implemented, either in England or elsewhere. No studies to date have attempted to identify the proportion of hospital admissions that could have been avoided amongst patients with palliative care needs, given existing and current local services. This study aimed to examine the extent of potentially avoidable admissions amongst hospital patients with palliative care needs.MethodsA cross sectional survey of palliative care needs was undertaken in two acute hospitals in England. Appropriateness of admission was assessed by two Palliative Medicine Consultants using the following data collected from case notes: reasons for admission; diagnosis and co-morbidities; age and living arrangements; time and route of admission; medical and nursing plan on admission; specialist palliative care involvement; and evidence of cognitive impairment.ResultsA total of 1359 inpatients were present in the two hospitals at the time of the census. Of the 654 consenting patients/consultees, complete case note data were collected for 580 patients; the analysis in this paper relates to these 580 patients. Amongst 208 patients meeting diagnostic and prognostic criteria for palliative care need in two acute settings in England, only 6.7% were identified as ‘potentially avoidable’ hospitalisations. These patients had a median age of 84. Half of the patients lived in residential or nursing homes and it was concluded that most could have received care in this setting in place of hospital.ConclusionOur findings challenge assumptions that, within the existing configuration of palliative and end of life health and social care services, patients with palliative care needs experience a high level of potentially avoidable hospitalisations.

Design-Led Service Improvement for Older People

In the UK outpatient services are a major element of the health service for older people and large numbers are requested to attend hospital-based outpatient clinics. However, it has been reported that outpatient clinics have fallen behind improvements in inpatient and primary care and they are seldom the focus of the patient-centred quality agenda that promotes personalised care. Significant proportions of older people fail to attend their appointments and there are few studies into the experience of older patients using outpatient services. In this paper we report on a design-led service improvement project that involved older people using a medical outpatient service and its staff. The project was facilitated by an interdisciplinary user-centred healthcare design team consisting of designers, technologists and health professionals formed to develop new participatory design methodologies and translate design thinking and practices into health services. A significant finding of the project is that an outpatient service extends beyond both the clinical encounter and the physical extent of the building, with many touchpoints before and after an appointment, such as confirmation letters, journeys and wayfinding, and staff interactions. These significant interfaces and interactions constitute critical factors in the experience of patients and staff and impact upon the ability of the service to perform its clinical role. We argue that through the deep engagement, achieved by capturing the lived experience of patients and staff, the clinic can be reconceived and reconstructed from a user perspective and thus improve its clinical effectiveness and enhance the quality of its service. We discuss the benefits and practicalities of using an experience-based approach to service improvement in health care, and we describe the improvements and changes co-produced with the users of this outpatient system.

A narrative literature review of the evidence regarding the economic impact of avoidable hospitalizations amongst palliative care patients in the UK

Abstract Background The need to more fully understand the economics of palliative care provision is widely acknowledged; however, the evidence base regarding the extent of potentially avoidable admissions in the last year of life, and the link between reducing/redistributing overall costs of end-of-life care has not been previously evaluated. Aim A narrative review of the evidence relating to the potential economic impact of reducing avoidable admissions among palliative care patients in the UK. Methods Ten electronic bases were searched in 2010 using key terms to identify UK literature relating to the economic consequence of avoidable hospital admissions among palliative care patients. Results Five studies met the inclusion criteria. Two were randomized controlled trials comparing the addition of new services to support patients in the community at the end of life with the existing standard service provided; one was a descriptive analysis of the change in usage and costs of health care services following the introduction of two community-based services; two were retrospective analyses of patient records for patient who had died in hospital to estimate the proportion of final admissions that could be classified as avoidable. Conclusions The evidence base from the UK relating to the economic impact of avoidable admissions in palliative care is limited. Although two recent retrospective studies suggest that there are currently high levels of avoidable admissions, the feasibility of avoiding such admissions and the full economic consequences of such changes have not been clearly demonstrated. Further evidence is needed to provide a more robust estimate of the extent to which the additional costs of providing high-quality community support are offset by reduced inpatient usage by palliative care patients. Prospective studies are needed which seek to demonstrate the scale of admissions which can actually be avoided in clinical practice, when issues such as capacity constraints come into play.

Economic analysis of potentially avoidable hospital admissions in patients with palliative care needs

Abstract Background There is a widely acknowledged need to understand more fully the economics of palliative care provision in the UK. In particular, the economic impact of reducing avoidable hospital admissions among patients with palliative care needs has not been extensively researched. Aim A recent survey of two English hospitals identified patients with palliative care needs and the proportion of these patients whose admission was potentially avoidable. Using these data, the economic impact of avoiding such hospital admissions is estimated. Methods Costs were estimated by attaching an Health Resource Group (HRG) code to each admission classified as potentially avoidable in order to determine the possible savings to be made. Alternative places of care for these patients were identified and estimates of the cost of supporting patients in these locations were derived using published unit costs. Results In the two hospitals surveyed, our study suggested that 7% of patients with palliative care needs could have been cared for elsewhere. The estimated cost saving of avoiding these admissions and supporting these patients in the community was £1527 for both hospitals over the survey period. This extrapolates to savings of around £180 000 per annum. Results were most sensitive to the cost perspective used and the estimated cost of the avoided hospital admissions. This exploratory analysis was limited by small study size and uncertainty in the costings. Conclusions Further research is required to gain a better understanding of the economic consequences of potentially avoidable hospital admissions and the extent of variations between localities and to clarify disparities in identified costs.

Appointment reminder systems are effective but not optimal: results of a systematic review and evidence synthesis employing realist principles.

Missed appointments are an avoidable cost and resource inefficiency which impact upon the health of the patient and treatment outcomes. Health care services are increasingly utilizing reminder systems to manage these negative effects. This study explores the effectiveness of reminder systems for promoting attendance, cancellations, and rescheduling of appointments across all health care settings and for particular patient groups and the contextual factors which indicate that reminders are being employed sub-optimally. We used three inter-related reviews of quantitative and qualitative evidence. Firstly, using pre-existing models and theories, we developed a conceptual framework to inform our understanding of the contexts and mechanisms which influence reminder effectiveness. Secondly, we performed a review following Centre for Reviews and Dissemination guidelines to investigate the effectiveness of different methods of reminding patients to attend health service appointments. Finally, to supplement the effectiveness information, we completed a review informed by realist principles to identify factors likely to influence non-attendance behaviors and the effectiveness of reminders. We found consistent evidence that all types of reminder systems are effective at improving appointment attendance across a range of health care settings and patient populations. Reminder systems may also increase cancellation and rescheduling of unwanted appointments. “Reminder plus”, which provides additional information beyond the reminder function may be more effective than simple reminders (ie, date, time, place) at reducing non-attendance at appointments in particular circumstances. We identified six areas of inefficiency which indicate that reminder systems are being used sub-optimally. Unless otherwise indicated, all patients should receive a reminder to facilitate attendance at their health care appointment. The choice of reminder system should be tailored to the individual service. To optimize appointment and reminder systems, health care services need supportive administrative processes to enhance attendance, cancellation, rescheduling, and re-allocation of appointments to other patients.