Sarah Pearce Senior Commissioning Manager End of Life care and Care Homes Coastal West Sussex CCG

Loads of reports and publications – contents were curated to identify and articulate 6 ambitions

Ambitions for palliative and end of life care: a national framework for local action 2015–2020 National picture Aligns with 5 year forward plan Responds to post LCP The Ambitions for palliative and end of life care mentioned earlier sends clear signals. It is a ‘national framework for local action’

Why an End of Life Care hub? Raise the level of identification of those in their last year of life by having end of life conversations at the right time, regardless of people’s care settings Build competence and capacity within the generalist workforce to identify and support people in their last year of life To ensure a coordinated approach to care planning (development and sharing) and delivery once people are identified as approaching their last year of life Make provision for greater access to EoLC services 24/7 Continue to improve access to specialist services on a basis of need rather than diagnosis As organisations with experience of and responsibility for palliative and end of life care we have made a collective decision to act together to do all we an to achieve for everyone what we would want for our own families. Work together to grasp the opportunity created by the drive for more integrated care to provide a framework for change. All records will be shared including the patient’s preferences at the end of life People should know what they are entitled to expect as they reach the end of their life.

How echo works What is it? 24/7 telephone helpline and coordination centre 24/7 CNS and consultant telephone support Bespoke supporting website Who can use it? Patients, families, carers, professionals What will it do? Provide advice and support Host EoL Register – core info, advance wishes, contingency plans Coordinate care, link services Share information between organisations Who will staff it? Band 6 nurses Band 3 admin Additional capacity in RAIT and H@H teams Staff from the specialist palliative care teams Conversations at the right time- drive identification The hub will affirm life and regard dying as normal. The hub will neither hastens or postpones death The hub will offer medication to provide relief from pain or distressing symptoms The hub will integrate psychological or spiritual care The hub will offer patients support to live an active life until patient dies The hub will signpost support to help the family cope during patient’s illness and then their own bereavement. Sarah Pearce- echo presentation for EROG 20.12.16

How echo works - referring a care home patient Identified as EoL using SPICT and clinical judgement Discussion Verbal and written consent Referral webpage/ phone Accepted once MDS received Letter and card sent to patient Referring to echo Referral Identification > conversation > consent > referral > assessment of need > advice, support, signposting, onwards referral, mobilise rapid response if needed > information sharing Identify using SPICT and clinical judgement EoL discussion with patient and information about the service Consent from patient to register - Information sharing, EoL register – written consent scanned into S1 or emailed to echo Referral using agreed S1templates MDS – Minimum data set – Data standard for referral to be accepted Patient materials – Leaflet with written consent form, registration letter, echo card, website Sarah Pearce- echo presentation for EROG 20.12.16

How echo will work – changing need Assess need Advice and support Update & share any information Task, refer, mobilise, communicate 24/7 telephone support from specialist palliative care nurses and consultants Rapid response in community and hospital discharge Now discussing how echo will respond to day to day enquires or changing patient need (right hand grey box) Changing need for existing service user Incoming call > assessment of need > advice, support, signposting, onward referral, mobilise rapid response if needed > information sharing Incoming enquiry about existing service user echo nurses will assess need and provide advice and support where appropriate and update & share any information (e.g. care plans etc.) If necessary echo nurses will act as an interface between other relevant services to refer and share information echo will have 24/7 telephone support from specialist palliative care CNS’ and consultants echo will be able to mobilise additional capacity in RAIT to provide rapid response services in the home echo will create a more formal link between acute palliative care teams and the Hospice@Home and Clinical Support teams to improve discharges echo will act as an interface and information sharing centre between all healthcare professionals and services involved in a patient’s care Sarah Pearce- echo presentation for EROG 20.12.16

What will be the benefit of using echo? Patient care in the last year of life meets patient and carer expectations More people are able to die in their place of choice with their care effectively co-ordinated Reduce inappropriate admissions and interventions in last year of life Right care, right place, right time Conversations at the right time- drive identification The hub will affirm life and regard dying as normal. The hub will neither hastens or postpones death The hub will offer medication to provide relief from pain or distressing symptoms The hub will integrate psychological or spiritual care The hub will offer patients support to live an active life until patient dies The hub will signpost support to help the family cope during patient’s illness and then their own bereavement. Sarah Pearce- echo presentation for EROG 20.12.16

Next steps – your views… How could we raise the level of identification in your care home? What resources would help you? Outstanding issues have been highlighted - medication availability, syringe driver competence and verification of death- what are your views on these issues? Sarah Pearce- echo presentation for EROG 20.12.16

www.echocws.org