Background The BaNES, Swindon Wiltshire ICB lead for aging well and palliative care recognised people with frailty were not having palliative care needs identified and discussed in virtual wards (Hall, Boulton, et al. Palliat Med. 2021;35(10):1832–1843) and requested more specialist input. End of life knowledge and skills needed development to better support patients and families. Hospice services were not optimally utilised.

Aim Establish person-centred proactive discussion and well-documented decision making, working collaboratively with the virtual ward team, and ensure smooth, timely transition to end of life care.

Method The hospice team led workshops for community staff to share project drivers and to consult about needs and approach. The hospice CNS worked with the virtual ward team using quality improvement methodology:

• Identify PDSA opportunities – e.g. daily access to hospice consultant.

• Promote and role model ‘ what matters to you’ (Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board. Advance care planning [internet] 2022) and advance care planning conversations.

• New ‘breakfast bap’ team meetings – launch SPICT–4ALL and REDMAP (Dodson. Nurs Older People. 2024 Feb 21; British Geriatrics Society. End of life care in frailty: advance care planning. Clinical guidelines. 2020)

• Create well–documented ReSPECT forms.

• Collect patient information, outcomes and patient stories.

Results 72 patients reviewed. Learning sessions achieved confidence to apply learning, using tools for assessment and conversations [60% pre-learning, 97% post-learning]. Enhanced working relationships across teams with positive patient stories e.g.: ‘I wish this conversation had happened ages ago.’ ICB workshop requested for 50 virtual ward staff in June 2024 - sharing learning and tools to help conversations. The value of a CNS with time to talk is recognised, enabling 31 ReSPECT and advance care planning conversations, previously not undertaken due to pace of work in virtual ward.

Project staff have high levels of job satisfaction, their roles are positively evaluated by the NHS team.

Conclusion Hospice and virtual ward teams are working more effectively together. Frailty, palliative and end of life needs are well-identified and staff are more confident to have conversations and plan for the future.