Marie Curie Managed Care Service Community Nursing

Transcription

1 This is an official Northern Trust policy and should not be edited in any way Marie Curie Managed Care Service Community Nursing Reference Number: NHSCT/12/552 Target audience: All staff referring to and availing from Marie Curie Nursing Services Sources of advice in relation to this document: Patricia McDade Assistant Community General Manager Wendy Magowan Community General Manager Roy Hamill Assistant Director Primary & Community Care Services Replaces (if appropriate): NHSCT Palliative Care Support Team (Community) Operational Guidance (NHSCT/09/184) Type of Document: Directorate Specific Approved by: Policy, Standards and Guidelines Committee Date Approved: 2 April 2012 Date Issued by Policy Unit: 11 June 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves

2 Marie Curie Managed Care Service Community Nursing - Primary & Community Care for Older People Services Introduction The Northern Health & Social Care Trust (NHSCT), commissions the services of Marie Curie Cancer Services to provide a range of additional care and support to palliative patients within their own home who are at end of life. End of life care is simply acknowledged to be the provision of supportive and palliative care in response to the assessed needs of patient and family during the last phase of life. Marie Curie Services are used to support relevant patients resident in the NHSCT including malignant and non-malignant disease. Aim of Policy This document provides guidance on accessing Marie Curie services within the Primary Care & Older Peoples Directorate The purpose of the Marie Curie Managed Care service is to enable the current partnership arrangement between the Northern Health and Social Care Trust and Marie Curie Cancer Care to adopt a more coordinated approach to the delivery of Marie Curie community services which will result in: More patients achieving their preferred place of care at the end of their lives A reduction in avoidable emergency hospital admissions. A reduction in strain and anxiety for patients, their carers and family Improved quality of life and the promotion of dignity and self worth for patients An increase in the number of people supported to die at home if that is their wish Equity in the allocation of care The allocation of care will be based on the prioritisation of need Policy Statement Functions of the service To provide palliative nursing care within the clinical competencies of a Marie Curie Senior Health Care Assistant or a Registered Nurse in the patients home based on assessed need. Service will be delivered by a Registered Nurse or a Senior Health Care Assistant based on patient/family assessment and determining of care requirements within the allocated resource Hours of operation of care Marie Curie Nursing Service is provided 24hrs/day 365 days/year 1

3 Access to Marie Curie Nursing Service Access to Referral Centre is 363 days / year (closed Christmas Day and New Year s Day) Determining of care requirements will be carried out Monday to Friday from 9am to 5pm by a Senior Registered Marie Curie Nurse in conjunction with the District Nursing Service. If a District Nurse requires care for a patient outside normal working hours Monday Friday, 9am 5pm, the Marie Curie Referral Centre can be contacted on until 8.45pm. Patient updates or urgent care requests will be accepted at this point. The Marie Curie Senior RN responsible for the Managed Care Service will then contact the referring District Nurse at the first available opportunity during normal working hours to determine ongoing Marie Curie Care. Referral Criteria Patients who are in the end stage of life Patients resident within Northern Health and Social Care Trust Patients registered with GP Patient over 18 years of age however this age limit can vary depending on exceptional circumstances Patients with malignant or non-malignant conditions Patient/carer must consent to care from Marie Curie Services (The Marie Curie referral criteria are set out in the Marie Curie Nursing Services a Guide for District Nurses.) Exclusion Criteria The Marie Curie exclusion criteria are set out in the Marie Curie Nursing Services a Guide for District Nurses Any patient exclusion will be discussed on an individual basis with the referring District Nurse. When patient referrals are in excess of the service capacity, the Marie Curie Clinical Lead Nurse (CLN) and District Nurse will work together to prioritise care. Discharge Criteria It is the responsibility of the District Nurse to inform the Marie Curie Nursing Referral Centre of the patient s death or admission to an inpatient unit. Any plan to discharge a patient from the service will be discussed with the referring District Nurse. Referral Process Referrals to Marie Curie must be made by a District Nurse, (Core District Nursing and Hospital Diversion Nursing Team) who will remain the gatekeepers of this service. Requests for access to the Marie Curie Services from other professionals groups must be made to the district nurse for assessment and suitability for onward referral. Referral Pathway Patient registrations are made to the Referral Centre on daily from 8 am to 8.45pm. A basic patient assessment is recorded at this time. An overnight request must be actioned by the referrer before 8.30pm to ensure a service can be set up 2

4 Call transferred to Senior Registered Marie Curie Nurse (coordinating for NHSCT) within normal working hours to discuss patient referral The Senior Registered Marie Curie Nurse will contact the family to introduce the service and arrange first visit which will include the Determining of Care Assessment (DCR) by a Marie Curie Registered Nurse. The Marie Curie Registered Nurse feeds back (DCR) assessment to Marie Curie Senior RN. Based on District Nurse and Marie Curie assessment a Marie Curie Care Package will be determined The Marie Curie Senior RN will ensure communication to all relevant parties i.e. the family, the District Nurse and the Marie Curie Nurse who will be visiting the patient. Marie Curie nursing staff and District Nursing team will continue to communicate with the Marie Curie Senior RN regarding any change to the patient s condition in order to facilitate ongoing determining of care. Referral Details Referrals to the Marie Curie Nursing Service can be accepted by telephone: Patient Assessment, Risk Assessment and Care Plan The assessment of nursing need must be undertaken by the District Nurse. All documentation, including risk assessment and care plan, should be available in the patient s home. For urgent referrals Out of Hours, a Marie Curie RN can undertake an interim risk assessment until nominated DN has had the opportunity to visit the patient and complete necessary documentation. Risk Assessment for Marie Curie Staff in the Patient s Home It is the responsibility of the referrer to identify any environmental risks within the home and pass relevant information to the Marie Curie Centre. The Marie Curie staff manages this by asking the referrers a number of questions i.e. are there any risks such as poor lighting /difficult access to the home/ animals Response Times & Prioritisation The response time of the service is up to 2 hours. The nurse should arrive at the patient s home within 15 minutes of the booked visit time. The Senior Marie Curie RN will prioritise patients based on conversations with the DN, patient and feedback from the RN or SHCA who has visited the patient. Patients will be given an Urgent Stable or Changing status by the DN at time of registration and updated as appropriate. (See Appendix 1) Communication to Nurse of Visit Allocation The Marie Curie Referral Centre is responsible for allocation of nurse to each shift. The Marie Curie Nurse will be informed of visit allocations by the Referral Centre. Handover The Marie Curie Senior RN will be responsible for ensuring the allocated Marie Curie Nurses receives hand over prior to visit. 3

5 Confirmation of Visit to Patient and Referrers Referral Centre Staff will inform District Nurse and the patient/family of the Marie Curie Nurse allocated and approximate time(s) of arrival of the visit(s). The Marie Curie nurse will contact the patient / carer 1hour prior to the planned visit. Late Arrival to Patient by Marie Curie Staff It is the responsibility of the Marie Curie nurse to inform patients on their visit list of delays to their schedule. Where this delay may have significant impact on patient care, nurses should telephone the patient to advise them of the delay/non attendance and establish the patients condition/need. Within normal working hours the Marie Curie Nurse must contact the Senior Marie Curie Registered Nurse so that appropriate action can be taken. Out of hours, the Nursing Support Service Centre Manager must be informed. Responsibility of Marie Curie Cancer Care Staff when Delivering Care The nurse will update the NHSCT Patient Held Notes patient s, if in the unusual event of there being no patient notes in the home or space available to write, the nurse will use Marie Curie Cancer Care single episode of care document and leave in the patients home. Death of a Patient on Marie Curie Nurse Caseload The Marie Curie staffs responsibility are: o to provide support to the family/carer after the death of the patient o notify the DN o notify the Marie Curie Nursing Referral Centre If the Marie Curie nurse is not present the District Nurse must inform the Marie Curie Nursing Referral Centre of the date, time and place of death Access to Marie Curie Referral Centre will be closed Christmas Day and New Years Day. During these times the Marie Curie centre will provide District Nurses with a list of Marie Curie staffing contact numbers.this will enable the District Nurse to update the Marie Curie staff if a patient is deceased Post Care Delivery Handover The Marie Curie Nurse is responsible for providing feedback to the Senior Marie Curie RN either directly or via the Marie Curie Referral Centre. The Senior Marie Curie RN will ensure the DN is kept informed of relevant clinical information. See Appendix 2 Contact Names of District Nursing Staff 1 st Point of Contact Senior Nurse 2 nd Point of Contact Specialist Practitioner Nurse Band7 (See Appendix 2 &2aWeekend contact details) Cancellation of Visits If a visit is cancelled the Referral Centre staff will be responsible for communicating with the patient, the Marie Curie Nurse and the DN. If the patient cancels the visit, they will contact Marie Curie Direct On and the Referral Centre will inform the Marie Curie Nurse and the Senior RN. 4

6 Patients with Unmet Demand The Marie Curie Nursing Service will make every effort to meet all referrals to its service. Unmet need will be monitored through quarterly meetings with the Trust. Where Marie Curie Cancer Care views the demand on this service as being regularly and significantly higher than capacity commissioned this will be reported to the commissioner and capacity and provision of the service reviewed. Key Workers All patients referred to the Marie Curie Nursing Service must have a named District Nurse responsible for patient care. The assessment of nursing need must be undertaken by the District Nurse. The Marie Curie Senior RN will work with District Nursing to agree the Marie Curie component of their care package. Obtaining Medication for a Patient Should further supplies of medication be required Marie Curie Nurses will liaise with patient s family and primary health care team to gain additional medication. Marie Curie Nursing staff may obtain medication on behalf of patients in exceptional circumstances only and when it is safe to do so. Marie Curie staff must adhere to Marie Curie Medicines Policy Administering Medication Marie Curie Cancer Care does not support the practice of verbal orders given by medical staff, all medications to be administered must be prescribed and in the patient s home as per Marie Curie Cancer Care Administration of Medicines Policy A verbal request can only be accepted by Marie Curie and NHSCT staff if there are changes to an existing medication.this verbal advice must be followed up by a written Prescription Vulnerable Adults The registered person (Regional Manager for Marie Curie) shall make suitable arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Marie Curie Cancer Care has a duty of care for its staff and does not tolerate abuse to its staff either verbal of physical The service follows the Marie Curie Cancer Care Adult Protection Policy. Patient Consent Refer to NHSCT Policy on Consent The District Nurse is responsible for obtaining and recording consent for referral into the Marie Curie from the patient. Marie Curie Cancer Care will make available relevant information to enable patients to make informed choices regarding accessing this service Training & Development Training will be provided to all Marie Curie Staff to ensure they are competent to carry out their role. This is included in the budget / service level agreement and will not bear additional costs to the Trust. 5

7 Sickness & Absence During Marie Curie Nursing Referral Centre hours of operation the Marie Curie nurse will contact the Marie Curie Nursing Support Centre who will reallocate the shift to Marie Curie nurses who have given availability for that shift and will notify Patients and DNs as required. Transport Marie Curie staff travel in their own cars. The Marie Curie Planned service will incur a mileage charge from the Marie Curie staff own home to the patient s home return. The Marie Curie Multi visit Service which operates from 8am-11pm will incur a mileage charge from the base to the Patients homes and back to base. Staff bases are defined as: Locality Address Magherafelt Antrim Community Services Centre, 60 Hospital Road Magherafelt. BT45 5EG Oriel House, 2-8 Castle Street, Antrim. BT41 4JE Ballymena East Antrim Causeway Ahoghill Health Centre, 21 Portglenone Road, Ahoghill. BT42 IFG Carrickfergus Health Centre, Taylors Avenue, Carrickfergus. BT38 7HT Robinson Hospital, 23 Newal Road, Ballymoney, Co Antrim. BT53 6HB Equipment The Trust should provide all equipment in the patient s home to enable the safe delivery of care to include clinical consumables, drugs, Personal Protective Equipment and Manual Handling Equipment Clinical Advice and Support The Marie Curie Cancer Care On Call Policy will apply for Marie Curie Staff Incidents and Complaints All incidents and complaints will be investigated by Marie Curie and relevant ACGM to be regularly updated on progress with investigation The service follows the Marie Curie Cancer Care Complaints Policy and Procedures Clinical Record Keeping The service follows the Marie Curie Cancer Care Records Retention Policy All information held by Marie Curie Cancer Care meets Caldicott Guidelines and the Data Protection Act. Marie Curie will document patient care in the District Nursing Patient Held records. This communication will facilitate an effective and speedy route for communicating with GPs and District Nursing. 6

8 Sharing of patient Information The service follows the Marie Curie Cancer Care Access to Health Records Policy Marie Curie Cancer Care and the Commissioner accept that patient and carer confidentiality is important. Both parties agree to abide by the Data Protection Act 1998 and relevant codes of practice All requests for access to Marie Curie records (whether living or deceased) should be referred to the Company Secretary. Processes for sharing patient information with other professionals must be agreed locally. Storage and access to Trust documentation will be as NHSCT Records Management policy. Reporting Mechanisms Marie Curie will provide the Trust with a monthly activity report, number of referrals received where no service could be offered and associated costs as per contractual agreement. Budget Arrangements Marie Curie will deliver the service within the budget allocated within the contractual agreement. This will include direct care and associated travel costs. Service Monitoring Arrangements Marie Curie will meet quarterly with nominated Trust representative to monitor service delivery. This is in addition to existing contractual monitoring arrangements. Target Audience All staff referring to and availing from Marie Curie Services Equality, Human Rights and DDA The policy is purely clinical / technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative formats This document can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. Marie Curie Cancer Care Regional Manager Patricia McDade Assistant Community General Manager Wendy Magowan Community General Manager Roy Hamill Assistant Director PCCOPS May be contacted with regard to any queries on the content of this policy. Monitoring and Review This policy will be reviewed 3 years from date of approval 7

9 Appendix 1 MCCC Palliative Nursing Care Needs Assessment This tool is to support the assessment of patients referred to the MCNS Service when all requests for patient care cannot be met. The development of this tool has been encouraged and has been supported by other professionals within Primary Care Trusts as a way to support the decision that those patients assessed as having more urgent need rather than those who where referred first will receive care as a priority. The following patients will be assessed by the Nursing Team Manager following referral where 1. Patients who are allocated no care by MCRC 2. Patients who are referred for more that 3 nights care per week 3. Patients who have a prognosis of days and have been receiving care for 7+ days 4. Patients who have been receiving care for more than 4 weeks 5. Any patient that the NTM feels should be assessed following discussion with DN / MCN or HCA or other professional The aim of this tool is to assess a patient's nursing needs and place them in one of the following care priority categories so that the allocation of care will be related to the assessed need: 1. Urgent needs 2. Patients and/or families with changing needs 3. Patients and families with stable needs Prognosis of hours to days Prognosis of days to weeks Prognosis of weeks to months Same day/next day response is needed The patient requires a high level of nursing The patient requires a low level of Rapidly deteriorating condition care nursing care Uncontrolled symptoms, requiring nursing The patient s needs are changing The patient is asymptomatic or their intervention The patient has symptoms that are unstable symptoms are well controlled. Carer unable to cope with High levels of patient/carer anxiety The patient is deteriorating slowly changing/unpredictable demands in The needs of the family/carer are unstable Low levels of patient/family anxiety patient s care with a risk of increasing further Planned care packages to facilitate Breakdown in care which will lead to an The patient is not in their preferred place of discharge inpatient admission care Rapid discharge from in-patient settings Urgent referrals can retain this category for up to five days Name of person completing

10 Appendix 2a District Nursing Contact Details Monday-Friday 9.00am-5pm excluding bank holidays Locality DN Base Telephone / Fax Ballymena South Elizabeth Reid SPN Slemish CSC BVH Site Cushendall Road Ballymena Mobile : Tel Fax Elizabeth.reid@northerntrust.hscni.net Ballymena North Vacant Anne Spence /Yvonne Eddis SPN Slemish CSC BVH Site Cushendall Road Ballymena Mobile Mobile : Tel: Fax: anne.spence@northerntrust.hscni.net yvonne.eddis@northerntrust.hscni.net Dorothy Glass Ballymena Rural Margaret Diamond Cullybackey Health Centre, Tober Park, Cullybackey dorothy.glass@northerntrust.hscni.net Mobile Mobile : Tel: Fax margaret.diamond@northerntrust.hscni. net Katrina Dolan (ML) katrina.dolan@northerntrust.hscni.net Mobile

11 Locality DN Base Telephone / Fax Antrim North Bronagh Butler - SPN Randalstown Health Centre 5 Neilsbrook Road Randalstown Mobile: Tel: Fax: e Mail: bronach.butler@northerntrust.hscni.net Antrim South Mary Kane Diane Torrens - SPN Antrim Health Centre Station Road Antrim Oriel House 2-8 Castle Street Antrim Mobile Tel: Fax: Mobile: Tel: Fax: E Mail: diane.torrens@northerntrust.hscni.net Glynis Whittle glynis.whittle@northerntrust.hscni.net Mobile Magherafelt Sadie Campbell - SPN Templepatrick Surgery 80 Castleton Templepatrick Diamond Medical Practice 1 st Floor Market Square Magherafelt Tel: Fax: Mobile: Tel: / Fax: E Mail: sadie.campbell@northerntrust.hscni.net Angela Conway Draperstown Health Centre, District Nurses Room, 6 Tobermore Road, Draperstown angela.conway@northerntrust.hscni.net Mobile

12 Bellaghy Medical Centre 76 William Street Bellaghy Maghera Health Centre 25 Church Street Maghera Draperstown Health Centre 6 Tobermore Road Draperstown Tel: Fax: Mobile: Tel: Fax: E Mail: Tel: Fax: Cookstown Ursula Gray - SPN Cookstown Health Centre 52 Orritor Road Cookstown Mobile: Office contact Fax: E Mail: ursula.gray@northerntrust.hscni.net Karen McGurk Stewartstown Health Centre, Hillhead Road, Stewartstown karen.mcgurk@northerntrust.hscni.net Mobile Moneymore Medical Centre Fairhill Moneymore Coagh Surgery 67 Urbal Road Coagh Tel: Fax: Tel: Fax: Oaks Family Practice 48 Orritor Road Cookstown Stewartstown Health Centre 50 Hillhead Stewartstown Tel: Fax: Mobile: Tel: Fax:

13 Newtownabbey South Karen Cairns SPN Pomeroy Surgery Lucy Street Pomeroy Loy Medical Loy Street Cookstown Dr Graham Loy Street Cookstown Whiteabbey Health Centre Doagh Road Newtownabbey Tel: Fax: DN FAX Tel: Fax: Tel: Fax: Mobile: Telephone No: Fax No: Newtownabbey Central Wendy Hamilton Anita Black SPN Glengormley Community Services Centre Ballyclare Road Glengormley Mobile Mobile: Telephone No: Fax No: Carrickfergus Diane Taylor SPN Ann Magill Lee Hewitt Ballyclare Health Centre George Avenue Ballyclare District Nursing Office Carrickfergus Health Centre Taylor s Ave Carrickfergus Mobile Mobile: Telephone No: Fax No: ballyclaredn@northerntrust.hscni.net Mobile Telephone No: Fax No: Mobile

14 Larne Jean Hamill/ Mary Boyle SPN Old School Surgery Station Road Greenisland Larne Health Centre, Gloucester Ave Larne Mobile: Telephone No: Fax No: Mobile : Tel: ext2192 Fax: Ailish Geier Whitehead Health Centre, 17 Edward Road, Whitehead Mobile Whitehead Community Services Centre Edward Road Whitehead Mobile: Telephone No: Fax No: District Nursing Office Carrickfergus Health Centre Taylor s Ave Carrickfergus Telephone No: Fax No: Causeway Ballycastle Moyle Eileen Irwin SPN Ballycastle Health Centre, Hegarty, Practice McLister, Practice Country Med Centre, Armoy Cushendall HC Mobile Tel Tel Fax: eileen.irwin@northerntrust.hscni.net Tel Tel

15 Anne Mc Cambridge Dalriada Hospital, 1 Coleraine Road, Ballycastle anne.mccambridge@northerntrust.hscni.net Mobile Ballymoney Siobhan Archibald SPN Cloughmills HC Rasharkin HC Fannin Practice Ballymoney Family Practice Mobile Tel Fax: siobhan.archibald@norhterntrust.hscni.n et Coleraine South Pauline Mc Kenna Irene McIntyre SPN Liffock HC Coleraine HC Killowen HC Kilrea HC Garvagh HC Mountsandel Surgery Mobile Mobile Tel Fax: irene.mcintyre@northerntrust.hscni.net Vacant Post Mobile Coleraine North Alison Blair - SPN Maureen Brown Portrush HC Portstewart Family Practice Lodge Health Bushmills Med Cent Portstewart Med Centre Mobile Tel Fax: alison.blair@northerntrust.hscni.net Mobile

16 Hospital Diversion Nursing Team Contact Details Moneymore mobile Antrim/Ballymena mobile Causeway mobile Whiteabbey mobile

17 Appendix 2b Weekend Contact details District Nursing Team Contact number / Lead Phone LARNE Including Whitehead, Islandmagee, Glenarm, Carnlough CARRICKFERGUS Including Greenisland BALLYCLARE GLENGORMLEY WHITEABBEY MAGHERFELT Including Draperstown, Maghera, Bellaghy COOKSTOWN Including Moneymore, Coagh, Stewartstown, Pomeroy ANTRIM Including Templepatrick, Randalstown, Toome (not patients registered with Crumlin GPs use TN ) BALLYMENA including Ahoghill, Cullybackey, Portglenone, Kells, Broughshane COLERAINE including Bushmills, Portrush, Portstewart, Kilrea, Garvagh, Castlerock BALLYMONEY Including Cloughmills, Rasharkin MOYLE Including Ballycastle, Armoy, Cushendall, Cushendun Coleraine North Coleraine South

18 Appendix 2c ACGM Contact Details: Patricia McDade Assistant Community General Manager 31 Garden Street Magherafelt Tel: Covering Magherafelt /Cookstown and Antrim North (Randalstown and Antrim) Jo Burns Assistant Community General Manager Whiteabbey Hospital Site Whiteabbey Tel: Covering Newtownabbey Central /Newtownabbey South and Antrim South Liz Mc Nabney Assistant Community General Manager Spruce House Ballymena Tel: Covering Ballymena Localities North /South and Rural Kathryn Carmichael Assistant Community General Manager Route Site 8e Coleraine Road Ballymoney Tel: Covering Causeway Localities Coleraine North /South /Moyle and Ballymoney Ashley Ramsay Assistant Community General Manager Moyle Community Services Centre Larne Tel: ext 6477 Covering Larne and Carrickfergus