Short description of the contract or purchase(s)
General Overview and Objectives of Services
The simplified end of life care pathway for Calderdale, expects the service to provide and support the delivery of high quality, evidence based, safe patient centred care.
It is vital to the success of the proposal that a thorough awareness raising programme be implemented across all professionals in the end of life care pathway. This will ensure maximum output is achieved. It is vital that all providers including the Calderdale CCG are committed to the education process in order to fully realise the patient and financial benefits.
To support implementation of this pathway, Calderdale CCG will commission an end of life facilitator to embed end of life tools, champion key quality standards across the pathway and coordinate training and education to meet local needs. There is currently no dedicated end of life care facilitator within the area. Key tasks of the facilitator role would include an Out of Hours Community Nursing Service. This would involve a dedicated nursing team, which will provide planned and crisis visits out of hours, as well as telephone support to patients and carers, and generalist palliative care advice and support to other professionals such as care home staff. It is proposed that this team is in addition to the existing structure and will be ring fenced for end of life patients.
The increasing complexity of patient needs resulting in increased demand on staff time is the basis for the proposed uplift in staff numbers. It is crucial for the out of hours service to be able to double up on staff numbers to ensure staff safety but also to deliver more complex care in response to the patient's needs.
The Out of Hours team will facilitate and support discharge out of hours from Calderdale and Huddersfield Foundation Trust. The discharge will be facilitated safely with the individuals consent and will work in collaboration with existing care providers. The team will also work with existing care providers and ensure handover notes are in place for discharges in-hours. This will contribute to a reduction in length of stay in terms of acute bed day's and will ensure more patients die in their preferred place of care.
This service will provide end of life patients and their carers/families with:
Support for community staff who need assistance/education in order to provide palliative care;
Provision of advice and support re specialist palliative care to existing clinical staff;
An integrated approach to care, working alongside existing community and primary care team. The patients GP will retain clinical responsibility;
Receipt and triaging of calls from patients and their families registered with a Calderdale GP;
Response to crisis calls by providing crisis nursing hands-on care including physical symptom management, psychological and social support;
Telephone advice and reassurance;
Follow up telephone support or home planned visit for patients identified by their key worker when other planned services are not available;
Planned nursing care to facilitate a patient's choice to stay at home;
Carer support immediately after death.
The objectives of the service are:
To support the existing District Nursing teams and step in when more specialist services are required, through the provision of advice and practical support for more complex situations.
To improve the quality and clinical effectiveness of care delivered at home to end of life care patients and their carers/families in Calderdale and to limit the physical and psychological suffering that patients and carers experience at end of life; maximising quality of life through the provision of rapid and effective care and support.
To ensure speedy access to end of life care is met in the community in a timely manner.
To decrease the length of time between seeking assistance and accessing specialised palliative care services in order to mitigate crisis events.
To act as a flexible, responsive service that will react to unscheduled demand out of hours.
To deliver a consistent response and comprehensive communication with other providers for example Hospices, McMillan Services and District Nurses.
To support the transition from care provided in an acute hospital setting to home in a safe and timely manner.
To educate patients and carers on self-care and the best use of services.
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