Abstract

Time is of the essence to facilitate a swift transfer home from hospital when someone is dying. The George Eliot Hospital NHS Trust, Mary Ann Evans Hospice and local community services have worked together to enable rapid discharge – one of the key NHSE transform agendas – and become embedded into practice.

This model is innovative as the hospice’s senior health care assistants visit the acute trust over seven days of the week and assess themselves for the service to become involved. This ensures fast response and rapid access to care at home in a cost effective way.

A small team, including community services, worked together to establish how services could work together to make swift home discharge possible and a ‘RIPPLE’ (Realising Individual Patient Preferences at Life’s End) pathway including documentation was produced for use across all the hospital.

Evaluation is ongoing and is led by the hospital team. The hospice receives feedback from grateful families and annually surveys families to ensure services are meeting needs of local people.

The outcomes are dying people’s choices and preferences are enabled and where possible they die in the place they wish and in the surroundings they most want to be in. Family carers are supported by an integrated care approach as all services communicate, plan and work together to make home death possible.

This successful service is highly relevant to national policy and demonstrates how using skill and expertise of the local services in an innovative and integrated way can truly make an impact.

The services receive some funding from the local commissioning group however, for significant increases in numbers of people requiring swift discharge to home to die then additional funds to increase resources would most likely be needed.