Background A well circumscribed area in the North of England already had an integrated specialist palliativecare service consisting of NHS community and hospital team and voluntary hospice providing inpatient,day, outpatient and at home services; was in the second national wave of the Transforming Acute Hospitals programme and has started to implement the Six Steps Programme in care homes.
Aims To provide a team that works 7 days a week across hospital, community and care home settings toeducate and support staff in caring for those patients recognised to be in the last year of life,especially those without specialist palliative care needs, and to proactively seek out and supporttheir families.
Method The TRANSFORM team was created, merging TRANSFORM Hospital Clinical Lead and End of Life Facilitator, Six Steps Care Home Facilitators and new posts to embed AMBER care bundle andAdvance Care Planning.
Consistent education is delivered by the team across all areas with practical support scaffoldinglearning.
Patients likely to be in the last year of life are identified on admission to hospital and support given toensure a co-ordinated approach to care and smooth transition between settings, whilst respectingwishes and preferences.
Strong clinical relationships developed between all services with regular contact with hospital and community teams and care homes.
The team supports cross boundary data collection highlighting areas of strength and opportunities forimprovement
Results Although only in existence since May 2014, figures already show an increase in numbers of staffreceiving palliative and end of life care education and a 30% increase in numbers of dying patientswhose wishes to be at home are respected and met.
Conclusion A corporate team approach has enabled the development of a trusted and reliable service. TheTRANSFORM team empowers and supports all health care professionals to confidently deliver highquality end of life care.
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