PILOT PROTOCOL SINGLE POINT OF ACCESS FOR END OF LIFE CARE PROVIDED BY CROSSROADS CARE MACMILLAN PALLIATIVE CARE SERVICE & MARIE CURIE CANCER CARE EASTERN CHESHIRE CLINICAL COMMISSIONING LOCALITY Crossroads Care is Britain s leading provider of support for carers and the people they care for. Crossroads Care are currently piloting work in partnership with Marie Curie Cancer Care to deliver a co-ordinated approach for end of life care through a Single Point of Access for the Eastern Cheshire Clinical Commissioning Group. Aim of the Service To provide a first class person centred supportive palliative care service for those individuals whose preferred place of care is their own home to enable them and their carers to have the best possible quality of life with dignity and respect, regardless of diagnosis. In the case of the South Cheshire Clinical Commissioning Group including Vale Royal the referral process will remain unchanged. Collaboration with Marie Curie This pilot will provide a Single Point of Access for both Crossroads Care and Marie Curie Cancer Care within the Eastern Cheshire Clinical Commissioning Locality. By using an integrated approach, efficiencies and overlap of process and delivery will be radically reduced. Whilst releasing valuable time for professionals who currently refer into these two organisations separately, this will enable a more co-ordinated and seamless approach for professionals, patients and their carer in the delivery of palliative care. Objectives: To provide a single referral process for Health professionals To deliver services appropriate to need based on assessment To improve co-ordination of care To provide equity of services for palliative care patients and their carers To enable patients and professionals to benefit from collaborative working between both organisations To provide accurate data regarding demand for services and unmet need To influence future commissioning of services To utilise existing resources effectively Service Criteria The service is for adults who have an advancing, progressive, incurable illness with a prognosis of less than 12 months. The patient should be registered by their GP practice on the Gold Standard Palliative Care Framework Register or equivalent.
There are 3 levels for priority of care: Urgent Changing Needs Stable Needs There are healthcare descriptors for each level Described in Appendix One. The individual wishes to remain at home but requires support with their health care to ensure their quality of life and medical needs are managed to the best they can be at their particular palliative stage. On referral, individuals may already be at home or waiting discharge from either hospital or a hospice. What the service provides Patient Pathway The service supports and compliments, but does not replace, the roles of the Primary Health Care Team, Macmillan Clinical Nurse Specialists, District Nurses and Allied Health Professionals. It is free at the point of delivery in line with the priority criteria. The service will be provided by Crossroads Care Macmillan Carer Support Workers and Marie Curie Nurses who are trained to the level of a Senior Health Care Assistant/RGN and have received additional palliative care training. In certain cases, additional specialist training may be required, which would be agreed and arranged between the Crossroads Care Macmillan Palliative Care Team, the District Nurse or other relevant healthcare professional. The service is flexible and responsive to people with health care needs and their carers around the 24hr period. It can be offered on an occasional or regular basis, for a few hours or longer periods, during the daytime, evening or overnight. The Marie Curie Cancer Care nursing service provides 9 hour shifts from 10pm 7am. Whilst every effort will be made to provide a comprehensive service, which will provide adequate support for the family, the level of service will be determined by the priority for care criteria, available funding and staffing resources. Referral For both Crossroads Care and Marie Curie services, referrals must be made by a health care professional, for example, the GP, District Nurse, Macmillan Clinical Nurse Specialist etc. The Health Care Professional involved must contact Crossroads Care Macmillan Palliative Care Team, by telephone on 01260 292850 - between 9am and 4.30pm Monday to Friday. Health Care Professionals can refer directly to Marie Curie Referral Centre over the weekend for urgent patients only on 08450 567899. In the case of patients registered with a Vale Royal GP, contact Crossroads Care Cheshire West & Wirral on 0151 343 1960. At this point they can discuss the needs and requirements of the individual with healthcare needs and their carer as far in advance as possible. Only in a crisis situation should referrals be made on the same day as the service is required.
At the point of referral, the Crossroads Care Macmillan Palliative Care Team will require the following information: Confirmation regarding health care need against priority for care Confirmation individual on GSF Register Name of the Person with Care Needs Date of Birth Address Diagnosis Telephone Number Carer/Next of Kin Indication of care and level of support required Person with Care needs/carer's awareness and perception of disease process Equality and Diversity Data Other professionals involved: GP District Nurse Macmillan Clinical Nurse Specialist Allied Health Professional Social Worker Marie Curie Other Information regarding: Health & Safety Safer Handling - mobility assistance Equipment Medication Symptoms Special Procedures Assessment In the case of a referral for the Crossroads Care Service: o A member of the Crossroads Care Macmillan Palliative Care Team will phone the carer or individual with care needs, usually the same day but within 3 working days, depending on priority, to make arrangements for an assessment/care planning visit. o The visit will be arranged at the earliest convenient time for the carer and individual with care needs, usually within 1 week. If necessary the initial assessment can take place at the Hospital or the Hospice. o A member of the Crossroads Care Macmillan Palliative Care Team will then visit the family to undertake the assessment and care planning to establish whether it is appropriate for Crossroads Care to Deliver a service Determine the needs of the carer/family members and the individual with health care needs, including the level and type of care or other needs Identify any potential Health and Safety issues o The Crossroads Care Macmillan Palliative Care Team will identify Carer Support Workers to provide the service and arrange additional specialist training if required. o The family will be given a Support File containing a Support Plan and a Weekly Booking Schedule which will give the name(s) of the Carer Support Worker(s) who will be providing the care and the times of their visits. The Care File will also include other relevant information and contact telephone numbers including emergency 'out of hours' telephone number. In the case of a referral for Marie Curie Cancer Care:
o District Nurses will make an initial assessment for a Marie Curie Cancer Care referral. A further joint assessment may be made by a Marie Curie Senior Nurse or Clinical Lead Nurse. o Marie Curie Cancer Care assessments that are carried out by the district nurse are available for the Marie Curie nurse to refer to in the patient's home The referrer will then be informed that the service has been arranged, and will be advised of the schedule of visits. They will be able to contact the Crossroads Care Macmillan Palliative Care Team at the Crossroads Care office between 9am and 4.30pm Monday to Friday, 01260 292850. For emergency contact only, the 'out of hours' telephone, 07967 002934 can be used. Care Provision The Services provide a person centred specialist service reflecting the needs of the individual and their carers. In addition to personal care which is sensitive to disease progression, the team can deliver specialist care to monitor symptoms and emotional wellbeing. Additional specialist training can enable the team to carry out other healthcare tasks as agreed and supervised by the referrer. The teams are highly skilled and focused on providing support to patients and family carers to help them cope with the individual's illness and their sense of loss. Review The referrer or named key worker must support the joint review of the individual regularly with Crossroads Care Macmillan Palliative Care Team and Marie Curie Cancer Care against the care priority criteria. They should also ensure the team is kept informed of any relevant developments or changes to the health care of the individual, such as increased/decreased care needs, a death, hospice or hospital admission. If it is found that the individual no longer meets the priority criteria, the referrer, named key worker, District Nurse, and other health care professionals involved will be included in discussions about discharge from the service and identification of any on-going support needs. Discharge If the individual and their carer require care support following discharge, the Crossroads Care Macmillan Palliative Care Team and Marie Curie Cancer Care will discuss options with them to ensure their needs continue to be met appropriately. Crossroads Care Cheshire East Manchester and Tameside have high quality services to support individuals with long term care needs. Additional Services If the family wish to continue to receive a service following discharge and have no alternative funding other than payment by them, Crossroads Care Cheshire East may be able to provide additional services on an individual basis. Crossroads Care...the people carers turn to
Marie Curie Cancer Care - We put patients and families first
APPENDIX 1 - PRIORITY FOR CARE The Priority Criteria is provided for guidance. The final decisions regarding the service will rest with the Crossroads Care Macmillan Palliative Care Team. 1. URGENT - PRIORITY 1 The patient has expressed a wish to be cared for at home at end of life (e.g. Preferred Priority for Care Document), is going home on Rapid Discharge Pathway or eligible for LCP for the Dying Adult (Liverpool Care Pathway) Prognosis of hours to days Same day/next day response is needed Rapidly deteriorating condition Uncontrolled symptoms, requiring health care support Carer unable to cope with changing/unpredictable demands in patient's care Breakdown in care will lead to an in-patient admission Rapid discharge from in-patient settings A significant step up in care is required Maximum service for a short period e.g. 1-2 days, which may include overnight care. In exceptional circumstances this category may extend for up to five days only. The service will be reviewed every 1-2 days. In the case of Marie Curie Cancer Care the District Nurse will review patients at least every two weeks or when there is a change in circumstances. 2. CHANGING NEEDS - PRIORITY 2 The patient should be on the Gold Standard Framework register (or equivalent) - Palliative Care, or if in hospital must be or have immediate plans to be placed on the GSF on discharge Prognosis of days to weeks The patient requires a high level of health care support The patient's needs are changing The patient has symptoms that are unstable High levels of patient/carer anxiety The needs of the family/carer are unstable with a risk of increasing further The patient is not in their preferred place of care A responsive service including daily health care support and carers breaks which may increase as the patient condition deteriorates. The service will be reviewed weekly 3. STABLE NEEDS - PRIORITY 3 The patient should be on the Gold Standard Framework register (or equivalent) - Palliative Care, or if in hospital must be or have immediate plans to be placed on the GSF on discharge Prognosis of weeks 6-12 months The patient requires a low level of health care support The patient is asymptomatic or their symptoms are well controlled The patient is deteriorating slowly Low/increasing levels of patient/carer anxiety Planned care packages to facilitate discharge Minimal input e.g. weekly carer breaks and will include some health care support. The service will be reviewed 4 weekly 27.1.2012