Background With an ageing population, economic deprivation and poor health, the increasing demand for Specialist Palliative Care (SPC) services is putting pressure on hospice and hospital beds. Audit has shown that where patients with Palliative Care needs express a preference regarding place of dying, over 90% choose their usual place of residence. There is no dedicated workforce available at either hospital or hospice to support transfers and accompany patients and carers to their preferred place of care at the end of life, if necessary staying with them until District Nursing Services and/or carer is in place at the home setting. An innovative approach of a dedicated Hospice Discharge Support Team was established.

Aims To support routine and rapid discharges (particularly out of hours) from hospital and hospice services to preferred place of care at end of life.

To accompany patient/family on their journey to ensure a smooth transition between services reducing anxiety

To improve Satisfaction of Care by reviewing ‘end of life’ complaints

To reduce hospital deaths where appropriate

Readmission avoidance

Methods An agreement between Hospice and Acute Services for a 12 month pilot Development of a Hospice Discharge Support Team with appropriate training Initial 85% funding secured through a Grants application to Help the Hospices Quarterly monitoring.

Results Achievement of patients preferred priorities for care via audit Data used to help to inform Commissioners to secure sustainable funding for continuation of the service Findings included in Quality Accounts.

Conclusion This service ensures a comprehensive holistic hand-over to the Primary or Care Home Healthcare Team, providing timely support so that necessary equipment and care packages can be put in place to ensure a smooth transition from care settings. This service strengthens stronger working relationships with Acute, Community Services, Care Homes and Specialist Palliative Care Services.