Background The Department of Health End of Life Care Strategy (2008) identified an increasing need for good end of life care in the community. The planning and reorganisation of this new community service has been developed to meet the demands of managing patients with more complex disease trajectories in an ever growing local population.

The new team Willen at Home is a new integrated community service, which combines the original Hospice at Home and Clinical Nurse Specialist Teams CNSs). The Willen at Home team was established in January 2019.The vision for this new team was to provide a holistic and responsive service using the combined skills of a multidisciplinary team. Patients are triaged according to their Phase of Illness and Performance Status (AKPS, 2005), and care is provided by the skill mix of professionals appropriate to their needs. Unwell, unstable or dying patients are triaged, ensuring a timely response as their condition changes. The integrated team comprises: Community Lead Nurse, CNS, Community Senior Nurse, Registered Nurses, Healthcare Assistants, Doctors.

Each day, staff are assigned to core roles:

• Telephone triage;

• Visiting;

• Monitoring.

This enables prompt assessment, prescribing, delivery of care and liaison with secondary care.

Impact of the new team In the new team, staff have a designated role for the day, ensuring that triage, assessment, visiting, prescribing and care planning are carried out in a personalised and timely way. As a result of this: Multidisciplinary team working means the patient’s care is tailored to their needs on the day. Clinical staff work collaboratively with allied services such as Social Work, Psychology and Patient and Family services. Nurse prescribers provide timely access to specialist medications. Patients can be reviewed on the day by a specialist doctor. More patients receive specialist care at home and are enabled to die in their own surroundings, avoiding unwanted or crisis admissions.