Background Patient feedback showed the need for improved responsiveness and a smoother experience of care. To meet our community’s unmet needs we needed to reach 1,300 more patients and 700 more carers annually over five years. Some hospice services duplicated work. The existing structure/lack of administrative coordination meant clinicians spent unnecessary time on administration.

Aims

• Create more seamless pathways and a single point of contact (SPOC).

• Improve responsiveness for community patients in urgent need.

• Create a sustainable platform for growth.

• Set comprehensive KPIs to monitor the impact of new/improved services.

• Remove internal inefficiency and improve collaboration.

Method We created a new ‘Clinical Hub’ model of care to enhance existing services, better use resources and introduce new services that better responded to community patients in crisis:

• A new SPOC for all clinical inquiries.

• A new Rapid Response team (RRT) to respond to priority calls within two hours.

A new KPI structure incorporating responsiveness and reach monitored performance and care outputs. We have conducted mortality reviews since 2021 to review causes of delays in care. Having analysed the cases of community patients who died before review we have refined triage processes. We are introducing systems to ensure patients are seen within the most appropriate timeframe and have improved communication with patients, families and nursing homes.

Results The percentage of non-urgent patients supported within 14 days increased by 20%. With a dedicated team for urgent patients, the Community Nursing team has more time to support non-urgent patients. 50% improvement in patients achieving PPD. 20% more urgent patients supported within 48 hours. The SPOC has streamlined the patient pathway and administrative efficiency.

Conclusion Moving to a seven-day Rapid Response team service will further increase responsiveness.

Expansion of existing pathways gives more flexibility in the way teams work.