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P-192 From silo to collaboration: developing a transition palliative care multi-disciplinary team meeting
  1. Janet Reiss
  1. Compton Care, Wolverhampton, UK


Background Nationally there is a lack of support for young adults with chronic, life-limiting illnesses in transition from paediatric to adult services (Transition Partnership, 2012). Young people may lose contact with health services and their health can deteriorate (Harden, Walsh, Bandler et al., 2012).

Aims NICE Guideline 43 (National Institute for Health and Care Excellence, 2016) challenges adult services to take joint responsibility with children’s services for transition. We wanted to develop local networks to encourage referral of young people with palliative care needs to an adult hospice.

Methods Our referral data 2012–15 showed one transition patient referral, with extrapolation of national figures (Fraser, Miller, Hain et al., 2012) suggesting approximately 15 people (aged 16–19) in the locality with palliative care needs. We contacted local providers of palliative care to children, including children’s community nurses, children’s hospice and transition manager in our clinical commissioning group. We started six-monthly multi-disciplinary team meetings to discuss, with parent/carer consent, all patients aged 14+known to these services who might need adult palliative care, offer joint consultations and encourage referral. We have formal terms of reference for our meetings.

Results We have had three patients referred to our service in the last year, now supported by our home care team. One attends our day unit. Advance care planning is underway with two patients. Another is waiting for a transplant. Joint home visits are planned with a further two patients. For those who do not want referral yet, we write a standard letter to inform GPs of our service and that we welcome referrals of young adults.

Conclusions With this collaboration, more young people are being referred to our service and receiving continuity of palliative care. More GPs are aware of our transition service. This intervention was straightforward to implement, has had clear benefits to a local transition service, and would be easily replicable elsewhere.

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