Hua Mei Mobile Clinic End Of Life Care Programme

Reflections on End of Life Care inHua Mei Mobile ClinicNg Wai ChongMBBS, GDGMTsao FoundationDec 2012

Scope Hua Mei Mobile Clinic – its Function andDesign Case Study Case Series of Patients in the EoL Programme Reflections

Hua Mei Mobile Clinic as a Long TermCare Service - PURPOSE To support the frail older persons to live in theirhomes (until their deaths if dying at home weretheir wish) Live among families and other natural caresupports Having access to health care even if they are notable to come out of their homes To respect and honour their preferences Ultimately to instil a sense of peace and comfortin the older persons’ lives

Hua Mei Mobile Clinic as a Long TermCare Service - DESIGN A Generalist health-and-social care service Long Term Care at in the community for the frailest The key components that allow this Clinic to deliver on LTCin the Community1.2.Interdisciplinary Health TeamPrimary care approach* Community-oriented Geriatric and Gerontology training Special attention to Transitional and Palliative Care 24H coverage3.Emphasis on Care management, providing multi-dimensionaltrans-disciplinary intervention. Comprehensive assessment and care planning using InterRAI HomeCare, HMMC Initial Assessment and Care Plan Protocols Use of IT* Primary Care is defined has having 7 attributes (7 “C’s”) – First Contact; Comprehensive; Continual;Community-based; Care management; Communication towards Empowerment; Cost-effective

Assessment Mdm M, aged 83, was admitted to HMMC in May 2007. Her poor health beganin 1999 and gradually declined from being wheelchair-bound to bedbound andfinally total loss of her cognitive functions.Multiple chronic medical conditions:1.–––––––2.Physical Dependence 3.4.Parkinson’s DiseaseVascular dementia with BPSDRheumatoid arthritisAnaemia associated with general poor condition and malnutritionCataract in both eyesPressure ulcer of lower backProtein calorie malnutrition.Bed-bound and requires total care including tube feedingHigh risk of complications due to immobility: bed sores; pneumonia; constipation;UTI; contractures; DVT; recurrent hospitalizationsCaregiver StressFinancial Strain

Care Planning Goal Setting:– Based on patient’s aspirations, prognosis, rehab potential,informal and formal community resources Needs Assessment– Team’s assessment supplemented with interRAI HC Resources and Strengths– Social worker’s assessment and team’s assessment IDG Discussion on Care Plan Communication and negotiation with patient and family:– ACP; present care plan Final Care Plan

InterventionsEnd-stage Advanced Care PlanningParkinson’s DMultiple tritionPoor feedingBPSDNursing Care Training,NG TubeHospital Bed andRisk of Constipation,Solace and CounselingreclinablewheelchairUTI, Contractures,Risk ofbedsores, DVTCaregiver StressPneumoniaFinancial Support e.g.IDAPE,Access to 24H HotlineCaregivers areFree diapers and feedsFinancialduring crises Recurrentretired living onStrainsavingsHospitalizations

Assimilating End of Life Care inHua Mei Mobile ClinicComponents1.End of Life Care Training for Team2.Person-centred Care and Advance Care Planningfor All Patients3.Increased resourcing based on EstimatedPrognosis

Case Series HMMC EoL CareProgramme(1 Oct 10 – 30 Sep 12)

Case Load and Capacity ofHMMC 1 Oct 10 – 30 Sep 12– Total number of patients served 160Patients never beenserved on EoL CareProgramme 105Patients served on EoL Programme 55

Caseload for the EoL careProgramme 1 Oct 10 – 30 Sep 12 (2 years)

Patient Profilen 55 Mean Age: 87.4 Median Age: 87 Age range: 69 – 99

Financial Profile

Functional Statusn 55

Diagnoses Distributionn 55

Advance Care Planning 54 out of 55 patients received ACP– Either in person or through presumed healthproxy if absent mental capacity (None of thepatients have officially elected a Donee as perMCA)

Tube Feeding n 55Preference for Tube Feeding Actual Tube Feeding353029 (52.7%)2521 (38.2%)2023 (42%)Tube-fed15Not Tube-fed32 (58%)105 (9.1%)50Refuse/ Prefer notDid not refuse/ Prefer Tube FeedingUnknown2 patients had NG Tube Insertion against theirwishes in the hospital before their deaths

Preference for Place whereDeath Occur

Deaths 1 Oct 2010 – 30 Sep 2012– No. of Non-death Discharges 4– Deaths 36

Places where Deaths TookPlace n 36Number of Deceased who died in a Place againsttheir Wishes 53 were due to care givers’ choice2 lived alone

Symptoms in the Last Weekbefore Passing (n 36)

Cause of Deathn 36

Average Prognosis (Days) After admission into EoL Care Programme,death occurred after 173 days (5 months 22days) on average.

Utilization Rate of Hospitals before Deathafter Admission to EoL Care Programmen 36Service UtilizationAcute HospitalAdmissionsLength of Stay inAcute HospitalA&E AttendancesSOC AttendancesRemarksTotal25 admissionsMean1.5 per patient-yearTotal235 daysMean9 daysTotal25 attendancesMean1.5 per patient-yearTotal6 attendancesMean0.4 per patient-year25/36 *365/173235/25 (discharges)25/36 *365/1736/35*365/173(excluded 1 outlier with 22 SOCattendances)

Feedback by Telephone(conducted Nov 2011 and Oct 12)Phone survey among the Main Caregivers of Patients who have passed on from theProgramme QuestionsQ1. Do you feel supported by the team during thisperiod?Q2. Are there any other areas that we could havesupported you better?Q3. Do you feel that the patient had a good death?Q4. Is there anything else that you would like toshare with me?

Q3. Do you feel that the patient had a gooddeath?n 36

Discussion This is our first attempt in codifying End of LifeCare in a ‘generalist’ Home-based Long TermCare service– It is possible to deliver on palliative care for thelong-term chronic sick population by a generalistnon-hospice team– A cost-effective study might be helpful to establishif this could be a sustainable model of palliativecare

Majority of our patients suffer from Dementiaand Cerebrovascular Diseases– A strong therapeutic relationship, person-centredcare planning and timely communication family ispivotal– Nursing skills transfer and social workers’ inputs insupporting informal care are the maininterventions– Geriatric and psychogeriatric competencies areuseful

With ACP, timely communication and thefocus on psychosocial support, majority ofpatients– can die in a place of their choice,– need not receive Tube Feeding against their wish,– are perceived to have died a good death by theirfamilies

Specialist symptom management skills appearnot to be an important competency-requirement– The mainstay of palliative care in home-based LTCseems to be the domain of visiting community nursesand social work care managers– Nevertheless, the support of doctors within the careteam is crucial. These doctors need not be specialistsin Palliative Medicine.– However, specialist Palliative Medicine consultationshould be available from time to time

Prognostication based on the AmericanMedicare Local Coverage Determinationsappear fairly accurate – as the averagelifespan after admission falls within 6 months.May have implications on resource allocations– E.g. For Alzheimers Disease: FAST 7a 1 episode of fever within 1 year

Similarities and Differences between HMMCand most Home-based HospiceProgrammesSimilaritiesDifferencesEmphasis on Quality of Life – personcentred, rather than disease-centricTrajectory of life and debility difficult topredict for the very frail. May be verylong-drawn for years. Terminal stage notclear-cutMultidisciplinary team in assessment,care planning and care deliveryHaving multiple co-morbidities is thenorm. Dementia is very common.Emphasis on Symptom ManagementPain is less pronounced and may be lesscommonFocused on counseling andcommunication, and supporting informalcare partnersAs the terminal is not well-recognized,ethical dilemmas such as decision fortube-feeding and hospitalizations arefrequently encountered

Advantages of Assimilating EoL Carewithin a Primary Care-LTC Service Most older persons die in a frailty, ‘dwindling’trajectory1. It would be too costly to providespecialist palliative care service for all of them. A primary care-LTC empowered and enabled toprovide EoL Care may reduce the need forhospitalization2 Minimizes the need for patients to switchbetween care settings and primary care providers– Therapeutic rapport between patient/ family/ careteams can be harnessed to improve quality of care1.2.Lunney JR et al Profile of older Medicare decedents. J Am Geriatr Soc.2002; 50:1108-1112Report on the National Strategy for Palliative Care Oct 2011: Pg 24 Fig 6

Thank YouAcknowledgement:1. The late Dr Quek Hwee Choo for consistently conducting ACP and caring for thepatients and their families2. My team of Nurses and Social Workers for working very hard in the actual EoL care3. Juay for data collection and mining4. Mr Ang Kai Kok and Dr Quek Jing Sheng for bean counting, data mining andconducting the phone interviews5. Advisory Panel Dr Cynthia Goh, Prof David Matchar, Ms Peh Kim Choo, Dr Pang WengSun and Dr Mary Ann Tsao for giving me pointers in the beginning; Prof Timothy Quilland his team, and VNSNY for hosting and teaching me

Special attention to Transitional and Palliative Care 24H coverage 3. Emphasis on Care management, providing multi-dimensional trans-disciplinary intervention. Comprehensive assessment and care planning using InterRAI Home Care, HMMC Initial Asses