The Kirkwood recognised through its user engagement with patients and carers that coordinating palliative health and social care for patients and carers can be extremely complex, confusing and stressful. It appeared to be a contributing factor to carer stress. The crossover from social care to healthcare was often very abrupt with no lead support along the way. It was identified that having a lead service able to remove some of the strain and pressure was needed with the right level of skills and knowledge to support and navigate the system.
The Kirkwood set up a two-year pilot project called the Care Coordination team. The team have developed a trusted assessor relationship with the Local Authority and Continuing Healthcare team and work across both services to better service the patients and carers known to the team.
The Care Coordination team offer a telephone-based service with resource to complete home visits if required. The service is available seven days per week. The team have access to both health and social care records. They link in with PCNs, DN and Therapy services, carers’ services, benefits advice etc. The team lead on Fast Track funding implementation and care planning and keep abreast of changing COVID-19 implications on care and care services.
The team has gone from strength to strength and from a standing start has now doubled the number of referrals it receives (data to be shared for final poster). The service supports patients and carers over time and maintains review contact checking in as and when the patient and carers requires it. The team plan to be developing their capacity to support more people by developing a volunteer role within the team and as part of a wider hospice development of drop-in hubs where they are able to share their health and social care skills and knowledge.
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