Background Responding to stakeholder feedback and wider strategic developments, led us to review how we deliver care to be more social and personalised. Growing demand affected staff’s ability to work in a structured way leading to unmet expectations.
Aims We adjusted our approach to multidisciplinary team assessments with the following aims for patients and families:
To have an initial holistic assessment, using a SystmOne core template, by an appropriate hospice professional, not necessarily a nurse specialist
Their goals are identified, with a view to achieving results within six sessions.
This new model’s aims are to enable, equip and empower people by:
Maximising their existing support network
Sourcing alternative/additional support
Providing hospice support (six sessions of care model) – ‘sticking like glue’ to ensure issues are identified, goals set and a plan agreed.
Method A cross-organisation project group reviewed referral criteria and assessment processes. SystmOne templates were revised and the Outcome Assessment and Complexity Collaborative, Adult Social Care Outcomes Framework and Essex County Council’s ‘3-conversation model’ embedded in a core assessment. Staff were reorganised to enable a more responsive service.
Results Early indications are that this will achieve:
Common understanding for hospice staff by working within one structure
More comprehensive, timely crisis response – ‘right person, right skills, right place, right time’
Multi-disciplinary teams using their skills from first holistic assessment – ‘right person, right skills, right place, right time’
Widening access to the hospice
Integrated health and social care assessment, adhering to Care Act 2014
Model potentially to be replicated across the local health system
All stakeholders clearer about what we offer.
Conclusion This model of care provides a clear structure for hospice professionals, empowers patients and families, ensures greater access to hospice care, responds to patient and family needs in a person-centred and timely way and provides evidence of outcomes and impact.
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