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Wandsworth End of Life Care Coordination Centre

A central point of contact that improves the coordination and utilisation of services and resources for end of life care patients and carers

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Who is your idea designed for and how does it reimagine the end-of-life experience?

Patients, families & carers often don't know about available services and HCPs may have difficulty arranging services and support from across the wider EoLC system. By improving communications between many different providers across health & social care the Centre facilitates access for patients in a joined up coordinated way, facilitating access to services for people dying in the community. It enables delivery of personalised care and improved quality of life by its caring responsive service.

The centre is clinically led, and Care Coordinators are available to talk with patients, carers and healthcare professionals over extended hours. Much work relates to approving fast track CHC applications, writing a care plan and arranging an appropriate package of care. The centre can prescribe and authorise equipment the patient requires at home, and can arrange in some cases for carer respite through the Marie Curie Planned Night Service. This enables the Centre to facilitate discharge home from hospital if that is what the patient wants, and care packages can be reviewed urgently and stepped up as needed.

The project includes a new dedicated EoLC District Nurse who works closely with community services in the care of people dying at home or in a Care Home. This enables a fast response service to meet changes in need and the nurse also provides much needed practical and emotional support in people's homes.  There is also a small cohort of Health and Personal Care Assistants deployed on a daily basis from the Centre who go into visit people and deliver personal care and elements of social care, plus carer support.  Other patients have access to care from selected social care agencies.

The Centre aims to support patients families carers and healthcare professionals, by improving communications across all the different service providers in the wider EoLC system, and to improve the quality of care and the patient and carer experience by improved responsiveness and facilitating access to existing resources. It enables wider access to expert end of life care advice and services based at the hospice as appropriate for many patients. It gives advice and support to patients and carers and is a resource for HCPs freeing up clinical time.

The Centre aims to improve anticipatory care planning, enabling people to have a say in what happens, and encourages patients and HCPs to discover people's wishes and preferences for their future care so as to align the care plan to the patient's choices. This may involve ensuring medications are available in the home in advance of immediate need, just in case, and facilitating this with local GPs and pharmacists.  In addition it involves improved communication with out of hours services and the Lead Clinician can complete Coordinate My Care (EPaCCS) records for patients as appropriate. 

The whole aim is to support dying people in the community setting, to ensure patients are cared for where they want to be, care is well coordinated, medications are available for good symptom control, that carers are well supported and access to services is facilitated. 


What early, lightweight experiment might you try out in your own community to find out if the idea will meet your expectations?

This is a two year pilot and we are presently working on a new specification for consideration of forward funding from April 2017, supported by an external evaluation by a research consultancy.

What skills, input or guidance from the OpenIDEO community would be most helpful in building out or refining your idea?

Enable the idea of Care Coordination to grow - the EoLC system is a virtual framework, with many different service providers from health, social care and the voluntary sector all involved. It's difficult for patients and their carers to know who to contact when needs change, no one knows what to expect, uncertainty and anxiety can build. It's important to enable people to achieve their wishes for their future care, to improve quality of care and of life - and to support carers well.

Tell us about your work experience:

Background in General practice. Presently in hospice setting. Work closely with EoLC commissioner.

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