Background: Internationally, policy calls for care homes to provide reliably good end-of-life care. We undertook a 20-month project to sustain palliative care improvements achieved by a previous intervention. Aim: To sustain a high standard of palliative care in seven UK nursing care homes using a lower level of support than employed during the original project and to evaluate the effectiveness of this intervention. Design: Two palliative care nurse specialists each spent one day per week providing support and training to seven care homes in Scotland, United Kingdom; after death audit data were collected each month and analysed. Results: During the sustainability project, 132 residents died. In comparison with the initial intervention, there were increases in (a) the proportion of deceased residents with an anticipatory care plan in place (b) the proportion of those with Do Not Attempt Cardiopulmonary Resuscitation documentation in place and (c) the proportion of those who were on the Liverpool Care Pathway when they died. Furthermore, there was a reduction in inappropriate hospital deaths of frail and elderly residents with dementia. However, overall hospital deaths increased. Conclusions: A lower level of nursing support managed to sustain and build on the initial outcomes. However, despite increased adoption of key end-of-life care tools, hospital deaths were higher during the sustainability project. While good support from palliative care nurse specialists and GPs can help ensure that key processes remain in place, stable management and key champions are vital to ensure that a palliative care approach becomes embedded within the culture of the care home.

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BackgroundUK policy calls for care homes to provide reliably good palliative and end of life (EOL) care (Care Commission, Better Care Every Step of the Way, 2009). Consequently an intervention was designed to enhance the quality of palliative and EOL care provided by seven care homes in Midlothian, Scotland. Phase 1 consisted of a high facilitation model led by a palliative nurse specialist. This involved inhouse training of care home staff and visits to care homes every 10–14 days which resulted in significant improvements in end of life care outcomes (Hockleyet al, 2010; Palliative Medicine, 24(8)). Phase 2 attempted to sustain the positive outcomes with a lower level of facilitation.AimTo establish the extent to which a lower facilitation model would sustain the results achieved during the high-facilitation period.MethodTwo palliative care nurse specialists each spent 1 day per week providing support and training to care home staff and GPs over an 18 month period.Results96% of patients who died during Phase 2 had an advance care plan; an increase from 53% following Phase 1 and from 4% at baseline. 57% of patients were on the Liverpool Care Pathway; up from 30% following Phase 1 and 3% at baseline. 86% of patients had a DNACPR status, up from 72% after Phase 1 and 15% at baseline. Inappropriate hospital deaths were 4%, down from 8% following Phase 1 and 15% at baseline.ConclusionsA lower facilitation model managed to sustain and build on the outcomes achieved during Phase 1. Two specialist nurses were able to strategically support and train staff to provide a high standard of end of life care to care home residents. This model will now be used to introduce a palliative approach in a much wider group of care homes throughout the region.