Background As a hospice we support patients, carers and families of patients with life-limiting illness across our local area. As a partner to one of our local community healthcare providers we have a shared ambition to improve hospital discharge and admission avoidance for patients and their families. This commitment to integrating with local providers led to the development of a joint project testing the feasibility of increasing shared clinical capacity - specifically targeting hospital discharge and admission avoidance processes to enhance patient outcomes.

Aim The aim of the Integrated Transfer of Care (ITOC) nurse role was to identify patients not known to our services who would benefit from referral to us. Our aim is to encourage earlier access to hospice services and reach more people, ensuring timely and holistic care.

Method A pilot commenced March 2023 with a hospice nurse working as part of the ITOC hospital team supporting discharge planning and facilitating transfer of care, linking into the hospice teams quickly and effectively. Additionally, we provide educational initiatives to empower hospital teams with a deeper understanding of our services and facilitate earlier identification of eligible patients.

Results Our ITOC nurse collaborated closely with community partners and hospital teams to streamline discharge planning. They conducted informative discussions with patients, families, and staff about palliative and end-of-life care options, ensuring realistic expectations. Rapid coordination of onward transfers was facilitated when appropriate. Additionally, our team provided education and training to various stakeholders, promoting awareness of hospice resources to support discharge and reduce readmissions.

Conclusion The pilot has been effective in reaching more patients with life limiting conditions. These new introductions have enabled patients and families to access services they were previously unaware of and reach people earlier on after their diagnosis, empowering people affected by life limiting illness to reach out for support relevant to them.