There is a growing body of evidence to support the need for better identification of people in their last year of life, followed by appropriate care planning and support. We also believe the longer the relationship we, as a hospice, have with the family, in the last year, the better the overall experience and outcome will be for all those involved. With this in mind we have developed the Pilgrim’s ‘Think, Talk, Act’ pilot.
We are working with four GP surgeries to proactively identify patients, utilising a software programme, who are at risk of dying in the next year and offer them access to information via a socially prescribed workshop in the community. The aim is to enable earlier engagement with healthcare professionals to actively make advance care plans. This is the THINK part of the model.
Patients will be categorised into those who have symptoms that could benefit from our Pilgrims Therapy services. These patients will be invited into the practice to TALK about their condition. To help tailor the referral, the patient will be asked to complete an IPOS form to identify any concerns or symptoms they currently have. Patients who are identified and categorised as severely frail will be ACTed upon and, if required, referred directly to Pilgrims Hospices for full service support.
The aims are to
Increase the percentage of people identified as likely to be in their last year of life – DH mandate.
Increase the percentage of people who have died who have been offered the opportunity for personalised care and support planning – UPC Target.
Work alongside primary care colleagues to help identify and support relevant patients. We will introduce proactive and personalised care planning for everyone identified as being in their last year of life – NHS Long term plan.
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