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P-16 Out of hospital model – getting a head start at care coordination centre (CCC) and planning all care together (PACT)
  1. Syed Qamar Abbas,
  2. Alison Kempthorne,
  3. Sonia Haigh,
  4. Carolanne Brannan and
  5. Sheona Evangeli
  1. St Clare Hospice, Harlow, UK


Introduction West Essex Clinical Commissioning Group (CCG), in line with NHS Long Term Plan (2019) intends to introduce an ‘Out of Hospital’ model to help patient care. St Clare Hospice recognises this to be an opportunity for improved working relationships with our community colleagues giving rise to the ability to reach more people and influence positive end of life care patient experience. This contributes to the hospice’s strategy.

Process The work requires improving community relationships, which is being addressed by:

  • Regular weekly meetings with district nursing teams.

  • Piloting named nurses in one primary care area and then reaching across all teams.

  • Virtual weekly meetings and monthly face-to-face with some teams.

  • Being an integral member of the CCC working group to agree working policies.

Direct clinical care is improved by:

  • Increased number of joint visits with community colleagues for patients with complex symptom management needs.

Educational work is carried out by:

  • Bite-size teaching as well as bedside support learning.

  • Educational opportunities through the hospice including access to monthly masterclass and quarterly ‘Care of the Dying’ webinar study days.

Analysis The first meetings started in December 2021 with one area. Over four months these were extended across the patch with five regular weekly meetings now. All Gold Standards Framework meetings are supported with the model of meeting being advice and support for palliative patients not necessarily registered with the hospice. Furthermore, support with advance care planning joint visits is provided to support difficult conversations.

Conclusion Quantitative data shows that hospice is reaching more people and able to influence and support their care needs. Qualitative data shows satisfaction of community colleagues is on the increase.

Presence at the Care Co-ordination Centre joint working group ensures palliative care will be embedded from the pilot planned for July 2022.

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