Background Patients with life-limiting disease often do not achieve their preferred place of care and death. The Hospital2Home service (H2H) has been created to enable patients whose treatment has moved to palliation only, to leave hospital and safely achieve their priorities and preferences. The H2H service is facilitated by a team of palliative care Clinical Nurse Specialists and is based on a successful research project undertaken in Australia (Abernethy, 2006).
Aim To demonstrate the effectiveness and impact of the Hospital2Home telephone case conference model. This service delivery model coordinates advance care planning, transition of care, enhances communication between the hospital and specialist community services, and where appropriate, establishes a shared digital Urgent Care Plan (Co-ordinate My Care). Conversations with the patient and those close to them form the agenda of the telephone case conference with community teams and GP. Symptoms, social needs, family issues and preferences are discussed.
Methods The data for this evaluation have been retrospectively extracted from the Hospital2Home database between January 2015 to June 2017. Demographics, diagnoses, preferences and service data have been analysed.
Results The data demonstrates that by establishing patient preferences, and sharing priorities via telephone case conferences, 76% of 544 patients were enabled to achieve their preferred place of death ie home or hospice and only 20.4% died in hospitals.
Conclusion Telephone case conferencing is an effective tool to promote safer complex discharges.
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