There is very little evidence which describes those models of hospice care that are the most effective in meeting the increasingly complex needs of people at the end of life or which elements within a model have contributed to better end of life care (1).
Princess Alice Hospice is one of the largest hospices in the UK, our care area encompasses some 1.2 million people and we works with four clinical commissioning groups. We have the capacity to care for 24 complex inpatients at any one time and to support over 800 patients and their families in the community.
In response to the challenges surrounding palliative and end of life care – and in order to meet the demands of our local population – we have developed a new model of care, Princess Alice Hospice at Home, which is focused on supporting increasing numbers of patients and families in the community.
Princess Alice Hospice at Home aims to:
- enable more people to be cared for and die in the place of their choice
- respond rapidly to provide timely palliative and end of life care
- support rapid discharge from hospital to home
- reduce unplanned hospital admissions.
The model incorporates four services designed to work in harmony and to complement our established community specialist palliative care (CSPC) team. The services are: triage, rapid response, night nursing and enhanced support.
We have designed triage to act as a command base. Two clinical nurse specialists (CNSs) from the CSPC team rotate into triage on a daily basis. All new referrals are processed with increased efficiency.
Depending on need, all referrals are forwarded seamlessly to other disciplines where the other elements of the model are activated in order to support patients and their carers.
This service also provides easy access to specialist advice for health professionals, generic advice for patients/carers not necessarily under our care, and timely response to patients with urgent needs.
We established a CNS role to work under the auspices of the CSPC team to respond to urgent calls, make urgent visits, support hospital discharge, support triage and to undertake CNS urgent caseload requests.
The role’s primary aim is to enable palliative care patients in the community to access prompt specialist palliative care services and to increase the number of patients achieving their preferred place of care and death.
Key results after one year are as follows:
- 81% of patients supported were new to us and required end of life care assessment and/or symptom control management, with nearly 60% of visits lasting 1–2 hours.
- 96% achieved their preferred place of death with 71% seen on the day of referral. During the visit 83% had an advance care plan discussed in order to help prevent further crisis; 71% of patients died within 10 days of the visit.
The evidence supports our clinical opinion that the vast majority of patients requiring a rapid response visit were at high risk of being admitted unnecessarily to hospital, acknowledging that patients and their carers ‘struggle on’ regardless of a potentially poorer quality experience.
This service aims to optimise the opportunity for patients to remain at home under our care when they are assessed to be terminally ill or have been discharged from our inpatient unit requiring additional nursing support.
Our night nursing service is now supported by permanent registered nurses and senior healthcare assistants working with hospice-trained bank staff to deliver around 40 night supports per month. This service is supported by funding from the CCG, the local community provider and ourselves.
We also provide an end of life care night response service. A registered nurse and a healthcare assistant can visit patients across a seven-day week and are available via the telephone for advice and support.
Our nurses also visit those patients who do not require end of life care but who are under the care of the district nurse in order to prevent an unplanned admission to hospital (for example, a blocked catheter or burst stoma bag). This part of the night nursing service is supported with funding by a local community provider and two CCGs.
Our enhanced support service (ESS) team is a multi-professional team coordinated by a CNS. The team includes practical care nurses, a specialist social worker, physiotherapists, occupational therapists and a specialty doctor. The patient’s named CNS also remains involved.
This element of the community model supports those patients who require multidisciplinary input and are most at risk of being admitted to hospital.
The ESS was established to facilitate complex palliative and end of life care provision at home to better facilitate patient choice around place of care and place of death.
We are funding this two-year development project which operates with ten ‘virtual’ hospice community beds across our care area. Our multi-professional approach sees daily MPT meetings to ensure that patients’ needs are met and resources allocated appropriately and efficiently.
Evaluation after one year demonstrates the service is responsive: 96% of 231 patients were seen within one working day. Some 89% of patients on ESS who expressed their preferred place of death achieved this, with 6% not recorded. Only 8% of patients died in hospital.
The four elements supporting Princess Alice Hospice at Home are specifically designed to be flexible and responsive, ensuring that as many palliative and end of life care patients in crisis have a better quality of life, an improved experience and achieve their preferred place of care and death. Inappropriate admissions to hospital will be avoided if these initiatives are achieved.
Our analysis demonstrates that each element is successful in isolation providing the right care by the right person at the right time – but when interlinked seamlessly with each other and our hospice ‘core’ services, this initiative ensures a far greater percentage of patients achieve their preferences.
This is a summary of a longer article: Spencer L. Hospice to home: a patient-centric multi-professional community approach. International Journal of Palliative Nursing. 2015; 21(5):245-250. Available at: http://www.magonlinelibrary.com/doi/10.12968/ijpn.2015.21.5.245
You can contact Lesley at email@example.com
- Calanzani N, Higginson IJ, Gomes B. Current and future needs for hospice care: an evidence based report. Help the Hospices Commission into the Future of Hospice Care; 2013. Available at: http://www.hospiceuk.org/commission