Background With the increased complexity of arrangements for safe discharge of palliative patients from an inpatient unit to the place of their choice, it became clear that this could no longer be incorporated within the daily work of the ward nurses. It was also recognised that continuity from pre-admission to discharge was essential for patients who felt anxious about entering a hospice. Working within a shift system, continuity over a seven-day period was increasingly hard to facilitate.
Aim In 2014, following a scoping exercise, a new role of "care coordinator" was introduced to ensure that patients and families were greeted on admission or sometimes at home prior to admission, and followed through their inpatient journey to a successful and timely discharge. The aim was that having one full-time nurse dedicated to this role would facilitate multi-professional working and strengthen links with community and commissioning teams to aid communication and swift discharge when time is short.
Approach Although other inpatient units have a "discharge coordinator" it was felt that a "care coordinator" for the whole inpatient stay would be beneficial for seamless care. This would allow people's choices in end of life care to be honoured, as well as facilitate planned respite admissions for medically stable patients due to increased efficiency of bed occupancy.
Outcomes One year on the new post has meant that bed occupancy has increased by 14%, patients are discharged in a smoother more timely way and families have a named contact for all enquiries.
Conclusions The care coordinator role has greatly improved patient and family care, increasedjob satisfaction for the nursing team and enhanced multi-professional working. Sharing the evidence of the difference this exciting new role has made could be a model for the other inpatient units to follow in the bid to improve seamless care.
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