Introduction Recognising that someone is entering the last year of life enables access to Palliative and End of Life Care (PEoLC). There is currently under-identification of people in the last year of life.
Aim To enable access to PEoLC through improved identification of the patients known to the Community Trust who are likely to be in the last year of life.
Method In 2014 all Community Trust Specialist Palliative Care Nurses (SPCNs) were integrated into seven community integrated care teams, each covering a population of @100,000. The SPCNs were co-located and managed within those teams. Targeted PEoLC training was delivered to all staff. The SPCNs were supported to improve PEoLC within their locality through weekly Specialist Palliative Care multidisciplinary team meetings, senior nurse leadership, clinical supervision and an internal clinical network.
Results Two of the seven localities have been the most successful in improving identification of people in the last year of life (57% increase).
These joint reflections from locality manager and SPCN appear key to the improvement:
Leadership from locality manager on integrating SPCNs
Weekly locality multidisciplinary clinical meetings to share ideas, opinions, reflect, debrief, give informal education
Increased visibility improves working relationships
more conversations, trust, respect,
team-work, better understanding of roles/workload
More shared care and joint visits undertaken
SPCN facilitation of team action learning and clinical supervision
Offer of uniform to SPCN
Conclusion Integration of community SPCNs can significantly increase access to PEoLC through improved identification of people in the last year of life.
Next steps A comprehensive education programme is supporting staff development with the aim of further improving both access to PEoLC and clinical outcomes.
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