Background The transition home for Specialist Palliative Care (SPC) patients is often complex; requiring multiple medications, equipment, healthcare agency support. Many patients go home to die which causes additional stress for patients/carers. Nationally, discharges are frequently unsatisfactory; a telephone survey of local outcomes was undertaken.

Aim To identify any concerns/problems arising and improve the patient experience by providing SPC post-discharge support/advice.

Methods A pro-forma comprising 11 questions was designed for call handling. All patients were called within 3 days of their discharge home. All patients were known to the experienced SPC nurses making the calls. Over an 8 weeks period 14 out of 45 discharges was audited.

Results 79% (11/14) were called within the timeframe. Respondents were patients (7), family (4), other (3). Two patients had died. All knew what their medications were for, how to take them and what their side effects were. Eleven had enough medications until they could arrange a repeat prescription, one had three days supply; pending dosset box. Thirteen (93%) were given the SPC 24-hour advice line number. District Nurses (DN) and personal carers had attended as arranged (21% and 57% respectively) and equipment supplied (29%); the remainder reporting that these were “not applicable”. Two ‘concerns’ were identified: one DN unaware injection required and another had taken patient's discharge summary.

Discussion It is not known why a DN took the discharge summary or why another was unaware of the injection; this information had been sent to them. Most SPC patients have at least one DNs, professional carers and/or equipment therefore the response ‘not applicable’ may have occurred because the call was made before their arrive; this needs further exploration.

Conclusion Patients were followed up in a timely manner and few concerns arose; those that did were resolved. The need for subsequent follow-up call/s is under review.