Inverclyde Community Integrated Palliative Outcome Scale

Ardgowan Hospice

Partner organisations: Inverclyde Health and Social Care Partnership, University of the West of Scotland

Many people with palliative conditions in the community have unidentified needs. A recent study showed community patients tended to have their physical needs met, but communication needs with health care professionals were unmet.

Other studies have shown that psychosocial and spiritual needs of palliative patients and their families are not identified as they are reluctant to raise these issues in primary care.

If these needs cannot be met in the community by the primary care team, then identification of these specialist needs and referral on to specialist palliative care services is likely to be beneficial.

This project tested the use of a patient-reported outcomes measurement tool - the Integrated Palliative Outcome Scale (IPOS) - to improve the understanding and assessment of palliative care needs of patients in the community by the primary care teams.

Using this tool, improved the support people received in primary care, to have their needs identified, interventions offered and outcomes monitored in an evidence-based way and, if required, be referred to a Supportive Care Clinic staffed by specialist clinicians from Ardgowan Hospice.

The project was supported by grant funding from the ihub's Improvement Fund in 2016-2017.

What was the approach?
The work is in line with the Strategic Framework for Action for Palliative Care, which set out the aim to provide palliative and EoL care to all who need it by 2020, and with the National Health and Wellbeing Outcomes in helping people with long term conditions to be at home as long as is reasonably practical with optimum quality of life.

Everyone on the palliative care register within the five participating practices was offered an IPOS assessment. This, combined with case note reviews, was used across general palliative care services to:
- assist in the understanding of what is important to the patient
- ensure a systematic approach to identify and meet their palliative care needs
- improve the number of appropriate referrals to local specialist palliative care services.
The team worked in partnership with members of the primary care team – predominantly district nurses and general practitioners - to explain the benefits of IPOS for both practices and patients, and to support them in their learning.

They supported ‘what to do next’ discussions after they completed their first IPOS (and subsequent PDSA cycles). Clinical case reviews with individual practitioners enabled reflective practice and identified key learning to share with the wider team.

Support and funding from the Improvement Fund helped develop:
- PDSA cycles
- the IT management systems for IPOS in the community setting
- clinical governance structures for the use of IPOS in the community and general practice
- champions to support scaling up of the projects within Inverclyde
- quantitative data analysis and evaluation.
We used the Model for Improvement as our preferred method and utilised various techniques to gather baseline data, such as cause and effect diagrams, force field analysis and process mapping. Working in partnership with the wider team we ensured open access and wide dissemination of findings for discussion and feedback that was used in the PDSA cycles and continuous improvement being undertaken.

Driver diagram Cause & effect diagram Force field analysis PDSA cycles

What was the impact?

“patient identified needs and priorities rather than clinician agenda”

By asking about issues there is a higher likelihood of identifying where a need is present and being met, leading to improved quality of life for patients. Formal feedback is positive about the use of IPOS in helping people give their healthcare professional an idea of what matters to them.

The data shows a dramatic improvement in the number of symptoms and issues enquired about and documented through use of IPOS, even with patients who were being seen regularly.

Significant unmet needs in all areas (physical, social, psychological and spiritual) were identified. This allowed action to be taken as necessary and included drug treatment, support and information to patients and families, referral to various specialists for information needs and referral to specialist palliative care for complex issues.

IPOS was also found to improve communication and could be used as a tool to facilitate conversations with complex patients, and within the team.

There has also been a strengthening in relationships between the hospice and local primary care teams.

Case Study 1

Case Study 2

Patient who had been given an IPOS for completion and found to have several issues was referred for specialist palliative care input but declined despite initial agreement with referrer. Follow up IPOS a few weeks later showed worsening symptoms with most scoring very highly. This allowed the district nurse to convince the patient to accept the help from the hospice nurse, giving support to the patient, her family and the primary care team.

District nurse visited gentleman with lung cancer regularly for dressing changes but it was not until IPOS was completed that the nurse learned that the patient was suffering from shortness of breath and panic episodes overnight. He also scored highly for not having had sufficient information. Subsequent to this IPOS an appointment with the lung cancer specialist nurse to address his information needs was set up by the district nurse and a prescription for medication to help with his shortness of breath was issued.

What was the learning?
“We all need to take a role in continually trying to improve patient care and we need to do that within the system we have, learning to overcome challenges as we go. If you start small and study the effect of the changes you make there is little risk and a lot to be gained even if it is only for one patient it can make a big difference to them.”

Integrating IPOS into the community setting has a number of barriers that have to be overcome, including:
- The need for a change in perception to shift from reactive patient care to proactive holistic care
- The concern that completing IPOS increases workload in an already time constrained environment
- The need for individualised teaching on the use and benefits of IPOS in the community
- The lack of IT resource to support the implementation of IPOS and sharing information across teams
- Requirement for shared learning and understanding between multi-disciplinary community teams and inter-disciplinary and Specialist Palliative Care Teams.
District Nurses

While it was anticipated the project would principally involve GPs, the work has been taken on predominantly by district nurses. From the case note review it became apparent that GPs tend to see acute problems in a short timeframe for assessment, whereas district nurses are more likely to see patients regularly and for longer.

The district nurses in two practices were the ‘first adopters’, and it was following meetings where they shared their experience of using IPOS that the GPs became more involved in using the tool. They championed the project, and with protected time to work on it, led the upscaling phase with their peers in other practices.

Sharing The Learning

ihub funding assisted in producing presentations and educational sessions. The team shared the learning as they progressed, with regular poster presentations at conferences: the NHS Scotland event, the Strathcarron Hospice annual conference, the Scottish Partnership for Palliative Care. Presentation at the Royal College of General Practitioners annual conference particularly, helped to engage GPs more in the project.

A poster presentation at the Institute for Health Improvement conference in Glasgow in March 2019 showcased the outcomes from the completed project.
What are the next steps?

In the short term, patients appear happy to use IPOS so there is potential for this to be used more regularly and to intervene at an earlier stage when issues are less severe, allowing improved quality of life.

In the medium term, identification of issues at an earlier stage may allow intervention which reduces the risk of patients reaching ‘crisis point’, taking up more GP time / requiring out of hours input / unscheduled (and often unwanted) hospitalisation.

Hopefully there is potential to improve patients' quality of life of patients and families feel their loved one has had a ‘good death’, which may in turn improve their bereavement and post-bereavement health behaviours.

The GP Palliative Care leads for 2 practices are planning on using IPOS within MDT Gold Standards Practice Meetings as a further cycle of improvement.

The Ardgowan Hospice Medical Team will continue to facilitate this process in the community within SPA time and disseminate to practices via the Clinical Nurse Specialist Teams at Ardgowan Hospice.

IPOS Champions will continue to integrate IPOS into the community setting within Inverclyde and up-scale this project within Kilmacolm and Port Glasgow Practice areas. This will form part of their normal working day.

Driver diagram	Cause & effect diagram	Force field analysis	PDSA cycles

Evidence and Evaluation for Improvement