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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

Photo of sdeas@royaltrinityhospice.london
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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.

This idea emerged from

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Team

Hi, interesting post! Any chance you could find an image to go along with it? Images help grab attention and tell a story with higher impact. You should be able to use the Edit Contribution button on the top of your post and follow the instructions to add images from there. Looking forward to seeing more of your inspiring insights on OpenIDEO.

Photo of sdeas@royaltrinityhospice.london
Team

Hello; this morning I've picked up a photo of three of the Coordination Centre staff at work but I cannot see how to attach it here. There doesn't appear to be an "attach" tab to operate this. Please advise.
Another thought:
24/7 community pharmacy access is crucial to delivering good end of life care in the community.  In the case of a person who is identified as EoLC and has chosen to die at home, even if equipment is available and all the advance care planning has taken place, if the person is symptomatic, suffering in pain for example, and medications cannot be obtained promptly then the care plan will break down as the only way an OOH visiting doctor can address the symptoms might be for the person to be admitted to hospital.
I think this is a situation which needs to be addressed and we need to ensure that EoLC medications can be obtained at all times, including weekends and at night. Locally we have an arrangement in place, just for EoLC medications, with a pharmacy in Earls Court that is open 24/7 to facilitate access 24/7 to appropriate drugs for good symptom control for EoLC patients. 
Similar arrangements could be developed all over the country if a community pharmacist (or possibly a pharmacy operating in the acute sector / hospice setting) could be recruited to be open or "on call" for EoLC medications. I couldn't guess at how many such contracts might be needed. Our local arrangement with the pharmacy in South West London covers a population of 330,000 people but no doubt this pharmacy could also cover more people in other directions if the contract were to be extended. It does involve someone having to travel to collect the prescribed medications and isn't perfect but it will come down to a balance between convenience and cost.
If medications are available in a timely way then patients' experience of end of life care should be improved, especially if there is a change in care need or a step up in dosage is required over the weekend / during the night, for example if a syringe pump should become necessary.  Patients will benefit and be more comfortable in the community setting, and unwanted, inappropriate hospital admissions reduced. I think this will help people to achieve their choices and preferences for their care at the end of life.