Background In Wandsworth, end-of-life care (EOLC) is provided by a range of organisations from health, social care and voluntary sectors. Feedback used to be that patients, carers and professionals were sometimes unsure who to contact during a crisis, which resulted in unnecessary hospital admissions. In 2014, the CCG commissioned us to set-up an Endof Life Care Coordination Centre with Marie Curie and St George’s NHS Foundation Trust as a two- year pilot to address these issues.
Aims The aims of the pilot were to:
Improve the quality of EOLC for patients and their families
Free up clinical time for professionals
Increase number of people able to die at home.
Methods A nurse-led coordination team based at the hospice arranges rapid packages of care and equipment and acts as a helpline for patients, families and professionals. An end of life community nurse provides face-to-face support to patients and families and a link to community nurses. Marie Curie health and personal care assistants offer specialised care. OPM have been commissioned to evaluate the model.
Results The service supported over 400 patients in its first year. The independent evaluation found patients and families felt supported to stay at home, and professionals noticed an improvement in the quality of care and the speed of organising care packages. Professionals report they have saved time on administration. Challenges included achieving buy-in from other providers and a lack of capacity to deliver care packages among care agencies.
Conclusions The care coordination model has improved the quality of care in the CCG and enabled more people to die at home. There is evidence admissions are being avoided and hospital discharges are faster. Now in our second year of the pilot, we are working with partners using evidence captured in the evaluation to shape the future model and hopefully secure ongoing funding.
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