SUPPORTED DISCHARGE SERVICE

SURREY AND SUSSEX HEALTHCARE TRUST IN PARTNERSHIP WITH MARIE CURIE AND ST CATHERINE’S HOSPICE

INTRODUCTION2

• SASH, Marie Curie and St Catherine’s Hospice are working in partnership to improve end of life care for SASH patients

• We have agreed to a two year pilot project, funded jointly by Marie Curie and SASH

• On-going evaluation processes which will define the project’s future

• The project was jointly developed with SASH, Marie Curie and St Catherine’s Hospice

• The project started in December 2014 and was brought about by a desire to improve patient experience while potentially saving bed days

• The model was based on work done by Marie Curie in other areas, adapted to meet local needs

THE SUPPORTED DISCHARGE MODEL 3

Two Key Components:

Discharge Liaison Practitioner

Based in East Surrey Hospital

Health Care Assistants

Provide care throughout SASH

catchment area

DISCHARGE LIAISON PRACTITIONER 4

HEALTHCARE ASSISTANTS 5

• Marie Curie recruiting a team of Healthcare assistants to cover 8am-10pm Monday- Sunday. Two on shift at any time

• Will meet patient immediately post-discharge and provide visits to cover the first 48-72hour period at home

• Aim is to bridge gap between start or re-start of other services

• The HCAs will be based in own homes to provide coverage for the whole catchment area

ST CATHERINE’S HOSPICE 6

St Catherine’s At Home Service

Is made up of a team of Specialist Palliative Care Nurses, The Practical Care Team, a Medical Team, Allied Healthcare Professionals and PFST

• The Practical Care Team was started at St Catherine’s Hospice in October 2008

• The Practical Care Team operates between 8am and 8pm - Monday to Sunday - 365 days a year

• Is made of staff nurses and health care assistants

• Has (until this project commenced) only accepted “internal” referrals

• Provides patients and families facing life limiting illnesses and end of life care at home, with personal care, nursing interventions, emotional support and respite services

• The service works alongside GPs and general community nursing teams

PROCESS FLOWCHART 7

THE MODEL OUTCOMES

OUTCOMES

Improve the patient and carer experience: through improving information to patients, involving them in decision making and offering them improved support in achieving their care preferences

Increase the quality of care: by increasing the number of patients able to access out of hours and enabling more patients to die in the place of their choice

Improving the patient transfer process: Improving the efficiency, speed and smoothness of the SASH end of life patient transfer process, freeing up the time of other staff.

Early identification and planning: Increasing the number of patients who are known to the palliative care team and reducing the length of stay for end of life care patients

Freeing up palliative care resources: having a dedicated resource for discharges will allow the palliative care team to see more patients

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BUSINESS CASE

• Based on service being able to see 14 patients per week

• Anticipated bed day savings of 3 per patient

• Project cost circa 400k

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SUPPORTED DISCHARGE SERVICE:WHAT IT IS AND WHAT IT IS NOT

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WHAT IT IS

AN ENABLER FOR PATIENTS TO DIE AT HOME IF THAT IS THEIR CHOICE

BASED WITHIN SASH WITH OUTREACH INTO THE COMMUNITY

A BRIDGING SERVICE TO ENABLE RAPID DISCHARGE AND RAPID ACCESS TO CARE FOLLOWING DISCHARGE

DISCHARGE LIAISON PRACTITIONER TO SPEED UP AND IMPROVE DISCHARGES FOR PATIENTS IN THE LAST YEAR OF LIFE

AN ENHANCEMENT TO EXISTING SERVICES

A PILOT TO REVIEW HOW TO IMPROVE THE QUALITY OF CARE DELIVERED TO PATIENTS BETWEEN CARE SETTINGS

A DEDICATED END OF LIFE SERVICE

ACCESSIBLE TO HEALTHCARE PROFESSIONALS WORKING WITHIN THE SASH CATCHMENT AREA

WHAT IT IS NOT

A HOSPICE AT HOME SERVICE

AN EXTENSION TO THE EXISTING MARIE CURIE PLANNED NIGHT SERVICE

AN ESSENTIAL COMMUNITY SERVICE

A SPECIALIST SERVICE. THIS WILL BE STAFFED BY BAND 6 AND BAND 3

ANOTHER NEW NUMBER

DIRECTLY ACCESSIBLE TO PATIENTS

AN ON-GOING CARE PACKAGE FOLLOWING DISCHARGE FROM HOSPITAL

A SINGLE POINT OF ACCESS FOR END OF LIFE PATIENTS AT THE HOSPITAL

EXAMPLE: FAST-TRACK SERVICE IN GLASGOW & LOTHIAN

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• Helps terminally ill people spend their final weeks at home rather than in hospital.

• Facilitates patients’ safe and timely discharge from hospital to their homes, as well as providing a short package of care post-discharge.

• Discharge liaison nurses are based at Glasgow Royal Infirmary and assess the patient’s care needs, make discharge arrangements and organise support for the period immediately after discharge.

• A team of senior Marie Curie health and personal care assistants are also available to support patients for up to three days post discharge.

• At this point they hand back to Primary Care and Community Services

A HEALTHCARE PROFESSIONAL‘S EXPERIENCE OF THE SERVICE

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“Our North-East Glasgow fast-track discharge service, in partnership with Marie Curie, continues to demonstrate that we can identify and offer patients a choice in where their palliative care needs can be met.

The fast-track service supports patients and families with palliative care needs in their own home by providing a service which meets both their health and social care needs. People at end of life who wish to die at home are enabled to do so thereby reducing length of stay in acute beds.”

Lorna Dunipace, Head of Primary Care & Community Services, NE Sector, Glasgow Community Health Partnership

LOCAL CHALLENGES 13

• Recruitment

• Large Catchment Area

• Variety of providers and processes

• Sussex Community Trust

• First Community Health

• Central Surrey Health

• Continuing healthcare Sussex and Surrey

• Straddling numerous CCGs

LESSONS LEARNT 14

• Importance of relationships

• Must build relationships

• Willingness to compromise and be flexible along the way

• Regular meetings

• Dual accountability for the roles within a partnership

• Policies, procedures and governance issues

• Line management and reporting

• Practicalities of working in a partnership arrangements

• Complaints processes

• Communications

• Development of operational policies etc

• Importance of commitment by all to working to support patients’ wishes

• Ability of all organisations to see the bigger picture

• Challenges with data

• Justifying the service, evaluating the service, and information governance

THANK YOU

FOR YOUR TIME