Chloe Longmore, Service Design Manager at Marie Curie speaks at NCPC's Building connections to achieve excellence in end of life care on 13 January, 2015. Surrey and Sussex Healthcare Trust, Marie Curie and St Catherine’s Hospice are working in partnership to improve end of life care by providing a supported discharge service for SASH patients. This is a two year pilot project, funded jointly by Marie Curie and SASH.

1. SUPPORTED DISCHARGE SERVICE
SURREY AND SUSSEX HEALTHCARE TRUST IN
PARTNERSHIP WITH MARIE CURIE AND ST
CATHERINE’S HOSPICE

2. INTRODUCTION
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• 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

3. 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

4. DISCHARGE LIAISON PRACTITIONER 4

5. 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

6. 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

7. PROCESS FLOWCHART 7

8. 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
8

9. 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
9

10. 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

11. 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

12. 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

13. 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

14. 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

15. THANK YOU
FOR YOUR TIME