Abstract

The co-ordination model came about from a Local Implementation Group which involves many different local professionals from the hospital, community, social care and hospice. The aim was to co-ordinate patient care through a 24 hour advice and support line, acting as the centre point that holds patient medical records. Communicating with patients, relatives, health care professionals both in the community and hospitals. Helping to reduce avoidable hospital admissions and enable patients to remain in their preferred place of care.

The team have built strong relationships with the local hospital, paramedics, community services and GPs. Attending regular meetings within all areas including Respiratory, Rare Neurological and Heart failure MDTs. We hold the medical records for all consented patients on our database (SystmOne).

Weekly data is sent to the local hospital, paramedic services and out of hours GPs about who is known to The My Care Co-ordination Team (MCCT). This ensures they have up to date information; included is DNACPR status and Preferred place of care.

The palliative care support workers provide hospital/hospice discharge visits to ensure transition back into the patient’s home is as smooth as possible. This has helped reduce the amount of potential hospital ‘bounce backs’. Personal care is provided for patients whilst waiting for a care package to start which assists in rapid discharge from hospital.

Some feedback: patients feel their care is well coordinated, MCCT has helped patients to remain in their preferred place of care. ‘We were lost, no idea what to do. MCCT enabled us to make the right decision for our palliative patient’, (Paramedic). Patients known to service: 559 with a population of 2 00 000. Hospital avoidances: 446 year 2017–2018.

The aims for the service in the future are to offer texting services, skyping and a responsive community nursing team to continue to increase hospital avoidances.