| Abstract: |
IntroductionRecognising that someone is entering the last year of life enables access to Palliative and End of Life Care (PEoLC). There is currently under-identification of people in the last year of life.AimTo enable access to PEoLC through improved identification of the patients known to the Community Trust who are likely to be in the last year of life.MethodIn 2014 all Community Trust Specialist Palliative Care Nurses (SPCNs) were integrated into seven community integrated care teams, each covering a population of @100,000. The SPCNs were co-located and managed within those teams. Targeted PEoLC training was delivered to all staff. The SPCNs were supported to improve PEoLC within their locality through weekly Specialist Palliative Care multidisciplinary team meetings, senior nurse leadership, clinical supervision and an internal clinical network.ResultsTwo of the seven localities have been the most successful in improving identification of people in the last year of life (57% increase).Abstract P-66 Table 1Number of people identified as in last year of life on System1 two localities (annual snapshot March)Year 2014 2015 2016 Number 183 223 288 These joint reflections from locality manager and SPCN appear key to the improvement:Leadership from locality manager on integrating SPCNsWeekly locality multidisciplinary clinical meetings to share ideas, opinions, reflect, debrief, give informal educationIncreased visibility improves working relationshipsmore conversations, trust, respect,team-work, better understanding of roles/workloadMore shared care and joint visits undertakenSPCN facilitation of team action learning and clinical supervisionOffer of uniform to SPCNConclusionIntegration of community SPCNs can significantly increase access to PEoLC through improved identification of people in the last year of life.Next stepsA comprehensive education programme is supporting staff development with the aim of further improving both access to PEoLC and clinical outcomes. |
