Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes.

Background: Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. Methods: The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. Results: The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally. Conclusions: Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland

Sustainable Development Policies in Europe

The objective of this paper is to investigate the actual situation in the shift towards the implementation of Sustainable Development Policies in Europe. The aim is to highlight the key role of the European Union in bringing about sustainable development within Europe and also on the wider global stage. It will show how the European Commission performs its commitment in reaching a sustainable regulation by issuing some documents and declarations. The paper frames the EU action into an international framework of strategies, agreements and policies on SD and, at the same time, provides an overview on experiences of SD strategy implementations at the national level, according to the commission pressing on MS to produce their own SD strategy and implement it. Indicators systems, issues of interest and fields of actions are compared: the analysis of these elements aims to highlight common scenarios of SD strategies that reveal the trends towards a more sustainable growth in the European Union

Evaluating the systematic implementation of the ‘let me decide’ advance care planning programme in long term care through focus groups: staff perspectives

Background: The 'Let Me Decide' Advance Care Planning (LMD-ACP) programme offers a structured approach to End-of-Life (EoL) care planning in long-term care for residents with and without capacity to complete an advance care directive/plan. The programme was implemented in three homes in the South of Ireland, with a view to improving quality of care at end of life. This paper will present an evaluation of the systematic implementation of the LMD-ACP programme in the homes. Methods: Focus groups were conducted with 15 Clinical Nurse Managers and two Directors of Nursing where the programme had been implemented. A semi-structured topic guide was used to direct questions that addressed implementation process, challenges implementing advance care planning, advantages/disadvantages and recommendations for the future. Data was analysed using manifest content analysis. Results: Five key categories emerged, with 16 corresponding subcategories. These subcategories emerged as a result of 37 codes. Key benefits of the programme included enhancing communication, changing the care culture, promoting preference-based care and avoiding crisis decision making. Establishing capacity among residents and indecision were among the main challenges reported by staff. Discussion: A number of recommendations were proposed by participants and included multi-disciplinary team involvement, and a blended approach to education on the topic. According to participants relationships with residents deepened, there was a more open and honest environment with family, end of life care focused more on symptom management, comfort and addressing spiritual care needs as opposed to crisis decision making and family conflict. Conclusion: The introduction of the LMD-ACP programme enhanced the delivery of care in the long-term care sites and led to a more open and positive care environment

Evaluating the systematic implementation of the "Let Me Decide" advance care planning programme in long term care through focus groups: staff perspective

Background: The ‘Let Me Decide’ Advance Care Planning (LMD-ACP) programme offers a structured approach to End-of-Life (EoL) care planning in long-term care for residents with and without capacity to complete an advance care directive/plan. The programme was implemented in three homes in the South of Ireland, with a view to improving quality of care at end of life. This paper will present an evaluation of the systematic implementation of the LMD-ACP programme in the homes. Methods: Focus groups were conducted with 15 Clinical Nurse Managers and two Directors of Nursing where the programme had been implemented. A semi-structured topic guide was used to direct questions that addressed implementation process, challenges implementing advance care planning, advantages/disadvantages and recommendations for the future. Data was analysed using manifest content analysis. Results: Five key categories emerged, with 16 corresponding subcategories. These subcategories emerged as a result of 37 codes. Key benefits of the programme included enhancing communication, changing the care culture, promoting preference-based care and avoiding crisis decision making. Establishing capacity among residents and indecision were among the main challenges reported by staff. Discussion: A number of recommendations were proposed by participants and included multi-disciplinary team involvement, and a blended approach to education on the topic. According to participants relationships with residents deepened, there was a more open and honest environment with family, end of life care focused more on symptom management, comfort and addressing spiritual care needs as opposed to crisis decision making and family conflict. Conclusion: The introduction of the LMD-ACP programme enhanced the delivery of care in the long-term care sites and led to a more open and positive care environment.PUBLISHEDpeer-reviewe

Mental state decoding versus mental state reasoning as a mediator between cognitive and social function in psychosis

Theory of mind deficits in schizophrenia have been parsed into mental state reasoning and mental state decoding components. We report that mental state decoding as measured by the `Eyes task? better predicted social function than mental state reasoning as measured by the `Hinting task\u27 in 73 out-patients with chronic schizophrenia. Mental state decoding task performance also partly mediated the influence of basic neuropsychological performance on social function. We discuss these findings in terms of the accumulating evidence that mental state decoding has particular relevance for understanding deficits in social function in schizophrenia

Mental state decoding versus mental state reasoning as a mediator between cognitive and social function in psychosis

Theory of mind deficits in schizophrenia have been parsed into mental state reasoning and mental state decoding components. We report that mental state decoding as measured by the `Eyes task? better predicted social function than mental state reasoning as measured by the `Hinting task\u27 in 73 out-patients with chronic schizophrenia. Mental state decoding task performance also partly mediated the influence of basic neuropsychological performance on social function. We discuss these findings in terms of the accumulating evidence that mental state decoding has particular relevance for understanding deficits in social function in schizophrenia