PA18 Heart of gold. integrating cross boundary care across different sectors with patients at the heart of care – a population-based public health perspective

Abstract

In response to the growing challenge of over-hospitalisation and fragmentation of care for people nearing the end-of-life, a key factor is to develop an integrated cross-boundary care approach to meet the population's needs. Gold Standards Framework (GSF) quality improvement programmes are widely used in the UK in primary care, care homes, hospitals, domiciliary care and hospices. By working together to a common plan, GSF can help be a vehicle for improvement with patients at the heart of care. To explore using GSF programmes in different settings to develop an integrated whole-system approach, with patients at the heart of care - the 'heart of gold' projects. A description of GSF used in different settings as a common language to develop better integrated cross-boundary care, with peoples' wishes and preferences at the heart of care. GSF improves the early identification, Advance Care Planning discussions and coordination of care reducing unnecessary hospital admissions. Findings from different sectors are presented from each setting, looking at whole-systems, and practical and qualitative measures of progress. Real improvements are being seen across whole areas using GSF as a vehicle for better co-ordinated care. 'Gold patients' and their families feel many benefits and there is greater openness and 'cultural change' in end-of-life-care, especially for the frail elderly. GSF can be part of the solution in developing such integrated care by developing a common 'vocabulary' of care for all people in any setting with any condition in the final years of life.