Background We are a large service with a catchment across three Clinical Commissioning Groups, serving a population of 832, 350. We have a 27-bed NHS inpatient unit (IPU) seeing 604 patients/year, a community team (CSPCT) seeing 1642 patients/year and hospital team seeing 1788 patients/year. Our IT system PCS is used across the palliative care service, but is not accessible to GPs or hospital services. Patients travel between all parts of our service and beyond but holistic cross-disciplinary information sharing is limited.
Aim To improve weekly holistic multi-disciplinary assessments of hospice inpatients and share these within and outside the service.
Methods The CSPCT is organised into three teams but the IPU was organised into two teams. IPU teams were restructured to align with the three community teams, with three consultant ward rounds and three post-ward round MDTs each week. A Community Clinical Nurse Specialist now attends the relevant MDT. An electronic holistic assessment form was developed and is projected at MDTs, facilitating communication, capture and dissemination of information within meetings and beyond. The forms are uploaded to the patients’ PCS record, accessible throughout the palliative care service.
Results An electronic survey was sent out to all members of the palliative care service. Themes arising include: improved participation from all disciplines; focussed care planning; improved access to and sharing of information; facilitation of better-informed clinical and discharge decision-making when patients moved across the service.
The future Dissemination of the Holistic Assessment Form to all:
Palliative care service users: uploaded as an attachment on PCS – already happening
Hospital users: will be uploaded as part of Trust Electronic Document Management System 2019 – to be evaluated
GPs: to be sent on discharge with patient’s Discharge Summary – to be evaluated
Health and social care professionals e.g. paramedics, out of hours services: to upload to Future Planning Templates.