Cost of effective discharge planning: how long does it take to complete a PEACE plan?
Editor – Studies show that older persons and/or those close to them would welcome discussions about potential future medical deteriorations in their health, if done sensitively and in plain language. Such advance care planning is more difficult or, in some cases, impossible in the presence of moderate to severe cognitive impairment. However, where an older person lacks the appropriate mental capacity for such discussions, the Mental Capacity Act 20051 allows for best interest planning between those responsible for care and those close to the older person. PEACE (ProactivE Advisory CarE) is a future care planning process that builds on the Mental Capacity Act and can be used for future care planning for older persons who have appropriate capacity and those who do not, and we have reported on this in a service review.2 The key findings of these reviews were that older people who were discharged to a nursing home with a PEACE plan were less likely to die outside of hospital and, compared with older persons without formalised medical care planning, need on average far fewer hospital bed days for subsequent hospital readmissions. These finding were, we argued, important as they provided surrogate measures to indicate that older persons with a PEACE plan may receive better end-of-life care.
The time to arrange and undertake the necessary discussions and paperwork for proactive care planning such as PEACE is often given as the reason that prevents clinicians from engaging in anticipatory care discussions with older people and/or those close to them, especially in the hospital setting. For this reason, we conducted an audit of the average time taken for the various components of a PEACE process (as per the policy in our trust) to be carried out. Some of these components – such as the mental capacity assessment of the older person – require clinical input, while other components – such as uploading completed forms onto various databases – require administrative support. This is important as the monetary costs of these components will be different and their differentiation can help when planning service developments.
Table 1 shows that the range and average time taken for nine different components of our local PEACE process. It should be noted that at the time of the audit most documentation was faxed to outside sources as our trust and local organisations were not universally on NHS mail; this is likely to have made some of the administrative times longer than is actually needed. The average time to undertake clinical assessments, discussions and documentation is approximately 2 hours. While this might appear a long time, a preliminary comparison between older people with and without PEACE plans being discharged from out trust (unpublished data) suggests this may save up toe 3 days of future hospital admission time on average, and thus overall may be cost effective. Further studies are required to assess this in more detail.
Conflicts of interest
The authors have no conflicts of interest to declare.
- © Royal College of Physicians 2017. All rights reserved.
References
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- Benson D
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