What are the fears and support needs of those living alone in the last year of life and who responds?

Background There is a general assumption that family caregivers will be available and willing to provide support to those living with terminal illness in the last year of life; but what of those who live alone at this time? Others (1) have highlighted the need for patients in this situation to develop trusting relationships with their professional caregiving network and with key professionals in particular. This can enable sensitive discussion and planning about future care wishes – a clear necessity as disease progresses. Design and methods Patients with advanced cancer, COPD and chronic heart failure (CHF), with a prognosis of less than 12 months, were recruited at clinical services sites in five European nations: Belgium, Germany, Hungary, The Netherlands and the United Kingdom. Data were collected using semi-structured interviews at baseline and at three months follow-up. Quantitative data were collected using POS, CANHELP Lite tools at monthly intervals and in weekly self-completed patient ‘diaries’. Interviews focused on how integrated palliative care services responded to patients’ needs and problems. A transnational comparative analysis was conducted using a qualitative thematic approach. Results Of 157 patient participants, 48 (30%) lived alone (range by country: 13%-41%). Of this sub-sample, the mean age was 73 years and 58% were women. Diagnoses were: cancer (n=27), COPD (n=13), CHF (n=7), not recorded (n=1). Many patients reported being fearful about the future; feeling lonely and isolated; feeling a burden on others; and problems with ‘the little things’. Conversely, many were able to give examples of where individual professionals and services responded to their needs quickly and with sensitivity. Informal sources of support from neighbours and friends were apparent and included practical help, emotional assistance and social engagement. Conclusion Commonalities across the participating nations in the fears and concerns of patients living alone in the last year of life were apparent. However, there was variability in how services responded to needs and in the extent to which these responses were integrated and coordinated. Lone patients are a potentially unrecognised sub-group with a particular set of needs in relation to professional engagement. Integrated palliative care services need to acknowledge this and respond accordingly. Further research into how palliative care service provision towards the end of life dovetails with informal support networks is required. 1. Hanratty et al. (2013). What is different about living alone with cancer in older age? A qualitative study of experiences and preferences for care. BMC Family Practice. 14:22. http://www.biomedcentral.com/1471-2296/14/22 On behalf of InSupC: EU FP7 funded project (Ref: 305555) on integrated palliative care in Europ

Enhancing integrated palliative care: what models are appropriate? : A cross-case analysis

Background: Effective integration between hospices, palliative care services and other local health care services to support patients with palliative care needs is an important international priority. A previous model suggests that integration involves a cumulative stepped process of engagement with other organisations labelled as ‘support, supplant or supplement’, but the extent to which this model currently applies in the United Kingdom is unknown. We aimed to investigate accounts of hospice integration with local health care providers, using the framework provided by the model, to determine how service users and healthcare professionals perceived palliative care services and the extent of integration experienced. Methods: Longitudinal organisational case study methods were employed using qualitative serial interviews (interval 3 months) with patients and family carers focusing on how services responded to their needs; and group interviews with health professionals. Data were audio-recorded, transcribed verbatim, and analysed by qualitative content analysis and combined across data sources. Results: The study focused on four hospices in northern England, including 34 patients (diagnosis: 17 cancer, 10 COPD, 7 heart failure), 65% female, mean age 66 (range 44–89), 13 family carers of these patients (48% partners), and 23 health care professionals. While some care fell short of expectations, all patients reported high levels of satisfaction and valued continuity of care and efficient information sharing. All hospices supported and supplemented local providers, with three hospices also supplanting local provision by providing in-patient facilities. Conclusion: UK hospices predominantly operate in ways that support and supplement other providers. In addition, some also supplant local services, taking over direct responsibility and funding in-patient care. They all contributed to integration with local services, with greater blurring of boundaries than defined by the original model. Integrated care offers the necessary flexibility to respond to changes in patient needs, however, constraints from funding drivers and a lack of clear responsibilities in the UK can result in shortfalls in optimal service delivery. Integrating hospice care with local healthcare services can help to address demographic changes, predominantly more frail older people, and disease factors, including the needs of those with non-malignant conditions. This model, tested in the UK, could serve as an example for other countries

How effective and cost effective are innovative combinatorial technologies and practices for supporting older people with long-term conditions to remain well in the community?:An evaluation protocol for an NHS Test Bed in North West England

Introduction: The Lancashire and Cumbria Innovation Alliance (LCIA) Test Bed is a partnership between National Health Services in England (NHS), industry (led by Philips) and Lancaster University. Through the implementation of a combination of innovative health technologies and practices, it aims to determine the most effective and cost effective ways of supporting frail older people with long-term conditions to remain well in the community. Among the Test Bed’s objectives are to: improve patient activation and the ability of older people to self-care at home; reduce healthcare system utilisation; and deliver increased workforce productivity. Methods and Analysis: Patients aged 55 years and over are recruited to four cohorts defined by their risk of hospital admission, with long-term conditions including COPD, dementia, diabetes and heart failure. The programme is determined on an individual basis, with a range of technologies available. The evaluation is adopting a two-phase approach: Phase 1 includes a bespoke patient survey and a mass matched control analysis; and Phase 2 is using observational interviews with patients, and weekly diaries, action learning meetings and focus groups with members of staff and other key stakeholders. Phase 1 data analysis consists of a statistical evaluation of the effectiveness of the programme. A health economic analysis of its costs and associated cost changes will be undertaken. Phase 2 data will be analysed thematically with the aid of Atlas.ti qualitative software. The evaluation is located within a logic model framework, to consider the processes, management and participation that may have implications for the Test Bed’s success. Ethics and Dissemination: The LCIA Test Bed evaluation has received ethical approval from the Health Research Authority and Lancaster University’s Faculty of Health and Medicine Research Ethics Committee. A range of dissemination methods are adopted including deliberative panels to validate findings and develop outcomes for policy and practice