St Christopher’s Hospice – coordinating care across Bromley

Categories: Care.

Tell us more about your award-winning service

Bromley Care Coordination (BCC) was commissioned by Bromley CCG in December 2013 to enable patients with advanced illness or frailty, thought to be in the last year of life, to receive timely and coordinated care.

The service aims to help people die with dignity in a place of their choice and reduce unnecessary hospital admissions.

Patients are given a high quality assessment at home of their health and social care needs and assessors will also discuss advance care planning and resuscitation, if appropriate. An appropriate ‘key worker’ is identified and referrals are made to other services in the borough as necessary.

Those under the care of BCC and their families have access to 24 hour telephone advice. If the patient’s needs increase and become more complex they can easily be transferred to St Christopher’s specialist palliative care community service. Otherwise they are monitored and followed up by the skilled team within BCC, who will help provide care, as necessary, at home when someone is dying.

What was the motivation for developing this service?

The need for the service was identified through working closely with GP’s and commissioners to address inequalities in dying – these patients might not have previously met the referral criteria for specialist palliative care. 

Its design acknowledges the changing shape of the Bromley population, notably its ageing population. The number of people aged 65 years and older is set to grow by 14% by 2021. In 2012 only 19.3% of Bromley residents died at home. 

How has the project developed since last year?

Over the past year we have had an increase in the number of referrals to the service.

We had anticipated that this group of patients would be known to district nurses or community matrons, however only 32% of the caseload were.

We managed to secure some ‘winter pressure’ money which enabled the community staff nurses to join the team and act as ‘key workers’ to those not known to anyone other than their GP. The key worker ensures that the patient is reviewed regularly and we can continue to coordinate the patient’s care and anticipate their future needs as their condition deteriorates.

How many people have you reached?

In the last year there have been 391 referrals with 176 deaths, of which 86% were at home; 87% of patients had a non-malignant diagnosis or frailty.

Early data from the local hospital also confirms a much reduced level of readmission to hospital for patients known to BCC and informal and formal feedback from users indicates high level satisfaction with care and the opportunity to remain at home.

What made you decide to enter the Hospice UK awards?

A real and positive difference to patient care is being achieved through this new approach to care.

The Bromley Care Coordination service is fundamental to this and is the result of a radical redesign of the end of life pathway, with strong links across Bromley healthcare – including community nursing and therapists, geriatricians from King’s at the Princess Royal University Hospital, Oxleas Trust for the management of end stage dementia and patients with learning disabilities, Bromley Council as well as the Bromley Clinical Commissioning Group. 

What did winning mean to the team?

We were thrilled to win this award. Our nursing and admin team worked hard establishing this new service to meet the challenge of bringing equity in end of life care for older people with advanced disease or frailty. 

Funding from Bromley Clinical Commission Group has ensured that patients get a timely and seamless service bringing together health and social care. It is truly a coordinated service for the residents of Bromley.

The Hospice UK Awards celebrate innovative work and people in the sector, and are open for entry until 8 September. There are awards for innovation in income generation and volunteering, as well as in care, an award for Volunteer of the Year and the Anne Norfolk Lifetime Achievement Award.

The awards will be presented at this year’s Hospice UK conference. All winners receive a glassware award and a one-day free conference place. Winning also gives you an opportunity to instil pride and morale in staff, volunteers, supporters and your wider community. There will also be PR opportunities for winning hospices to publicise their success.

To find out more about the awards, and to enter, go to the Hospice UK website.

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