This area’s hospital death rate is higher than the national average; in 2019, 49% of all deaths were in hospital (compared to 22% at home, 21% in a care home, and 7% in a hospice setting). Plans to reduce hospital admissions/deaths evolved as an Out of Hospital (OOH) model in partnership between the hospice, CCG and community health provider.
The model aims to strengthen community-based care pathways through proactive multi-disciplinary case management at a Primary Care Network (PCN) level that anticipates additional health and social care needs to reduce crisis. Additionally, work has started on the development of a Care Coordination Centre for specialist/complex cases that can no longer be dealt with at PCN level.
The model required a new way of working for the hospice Clinical Nurse Specialist (CNS) Service. The hospice developed a detailed leadership programme to equip the CNSs to have the confidence and skills to be assigned to a Primary Care Network and attend MDT meetings in their locality. In particular, the proposed OOH model was shared with the team, and they were asked to present the model (and their role in it) back to the Senior Leadership Team (SLT).
Results This has resulted in the CNS team developing their presentation skills and confidence levels before moving to the PCN aligned model. The CNS team showed their understanding of the model, and SLT were able to ‘correct’ where appropriate; it has been noted by the CCG that hospice staff have grasped the model and adapted quicker than non-hospice colleagues.
Conclusion The OOH model is a long-term project, but progress has helped the hospice to free up hospital beds and lower the numbers of people aged 65+ from dying in hospital [974 (18/19), 1,052 (19/20), 843 (20/21), 822 (21/22)].
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