The document summarizes a palliative and end of life care service called Coordinated, Safe and Integrated (CoSI) care. CoSI aims to [1] reduce hospital admissions and support patient choice for place of care and death, [2] provide enhanced coordination of care across partner organizations for patients with 6-8 weeks to live, and [3] lower costs compared to usual care. Since launching in 2014, CoSI has supported over 500 patients, with 76% receiving care within 48 hours and 100% of patients who died achieving their preferred place of death at home. Evaluation found acute care costs were £1,700 on average for CoSI patients versus £3,812 for others in their last 3 months

1. Palliative and End of Life Care:
Supporting Patient Choice
Jayne Cooper
Interim CEO and Director of Nursing
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2. 2008/9 hospital episode statistics
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3. Hospital episodes for people registered with a
NWS GP practice in the last year of life 2013/14
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4. What is CoSI?
• A Coordinated, Safe and Integrated (CoSI) service model
• Partnership and collaborative model across a number of
providers: Woking & Sam Beare Hospices (Lead Partner), Marie
Curie, Princess Alice Hospice and Virgin Care
• Responsive, skilled nursing and personal care for those who are
unstable, at a time of crisis, deteriorating, or dying
• Patients with estimated prognosis of up to 6-8 weeks of life
• Pilot evaluated and commissioned substantively by NW Surrey
CCG in March 2015
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5. CoSI Aims
• Reduced anxiety for patients and families of stressful and
inappropriate admissions to hospital
• Enhanced patient choice for place of care and place of death
• Improved experience of care and support at home
• Support rapid and safe discharge where the estimated prognosis
is only weeks or days
• Promote continuity and enhanced co-ordination across partner
organisations
• Reduction in average acute hospital costs per patient
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6. CoSI model
• Patients known to the Community Nursing Service in NW Surrey
• Co-ordination hub based at Woking Hospice
• 7 day clinical co-ordination providing single point of access,
dovetailing with out of hours community nursing
• Delivery team for care during the day and overnight
• Day resources: WSBH & PAH
• Night resources: Marie Curie & WSBH
• Clinical prioritisation to those patients with highest needs
• Monthly reporting to the Commissioning Support Unit –
monitoring of patients
• Quarterly reports to CCG
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7. Activity Report: April 2015 to March 2016
• 297 patients and their families/carers were supported
• 270 were new referrals to the service
• 37% of patients referred with an estimated prognosis of days
• 62% were referred with an estimated prognosis of weeks with
unstable and changing needs
• Average monthly caseload equates to 35 patients
• 82% of patients had a primary diagnosis of cancer
• Average patient age: 77
• 560 patients supported by CoSI since inception of pilot at the
beginning of June 2014
• Regular satisfaction surveys and clinical audit expertise
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8. Achievements and outcomes: April 2015 to March
2016
• 76% of patients had care commenced within 48 hrs
• 12 days is the average length of care episode per patient
• 8% patients admitted to hospital (acute episode; fall; unplanned
unstable symptoms; cord compression; patient collapsed; 999
call)
• Patients discharged from CoSI if needs stabilise beyond 6-8 weeks
and referred to CHC
• 100% of patients who died under CoSI care achieved their
preferred place of death (home)
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9. Achievements and outcomes: April 2015 to March
2016
• Excellent patient and family feedback
• Strengthened partnership working across providers
• A trusted provision for GP referrals
• Integrates with other aspects of hospice and end of life care
services, including those in the acute hospital setting
• Standardised processes and coordination across providers 24/7
Winner of KSS AHSN End of Life Care award and NCPC End of Life
Care Champions of the year 2016
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10. Feedback
Patient/carer surveys reported that:
• 100% reported they received care and support which fully met
their needs
• 100% of respondents had confidence in the CoSI team
• 100% said the CoSI service had met their expectations
• 98% said they were involved as much as they wanted to be in
the care given
• 96% said their care was well planned and organised
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11. CoSI impact on hospital episodes
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12. Evaluation and commissioning
• Not only high quality but cost effective…
• End of life care programmes difficult to evaluate effectively – no
end of life care coding in hospitals
• To evaluate the pilot NW Surrey CCG looked at those under the
care of CoSI against a control group of patients that had died in
hospital
• Activity patterns examined over the last year and 3 months of life
• Notable change in activity patterns for those under the care of
CoSI – average acute cost in the last 3 months of life £3,812 (non-
CoSI) vs £1,700 for those under the CoSI service
• An observed saving of over £2,000 per patient
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13. Our learnings and key challenges
• Collaboration is vital
• Standardise processes and approach
• Strong clinical and provider leadership
• Robust evaluation methodology and strong data infrastructure
• Hours of the service
• Resources aligned to the model
• Balancing the principles of continuity and clinical prioritisation
• Lack of joined up multi-provider record in the home
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14. Recognition
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NCPC End of Life Care Champions of the year 2016