Fylde Coast End of Life Care Kathryn Smith 13th June 2018

Coordination and Integration of Care Including Communication and Engagement Early identification of people who are at the end of their life, to ensure that the appropriate pathway to support them can used as early as possible Implementation of an Electronic Palliative Care Co-ordination System (EPaCCS) to enable the recording and sharing of people’s care preferences and key details about their care at the end of life Clarification of the options available for people at the end of life, including advance care planning, DNACPR, and preferred place of care, and the ways in which these options are communicated. Support for care home staff, residents and families

Advance Care Planning Timeliness and timelines of ACP Key Local Areas to Address Timeliness and timelines of ACP Appropriate use and awareness of ACP Recognition of the importance of ACP, by both health and social care teams, care home staff, and the public How ACP can be supported through the implementation is an Electronic Palliative Care Co-ordination System (EPaCCS) Best interest discussions  

Access to Packages of Care and Social Care Key Local Areas to Address Availability and timeliness of packages of care Variation in quality of packages of care Training on the implementation and delivery of packages of care The impact of rurality on the delivery of services on the Fylde Coast

Dementia and Mental Health Key Local Areas to Address Identifying those patients who would benefit from palliative care support including managing pain and distress Liaison between physical and mental health professionals to improve coordinated service delivery, assessment & co-working Understanding the impact of dementia and the best ways to care for people with dementia Effective training for those supporting people with dementia Understanding when and how to use the Mental Capacity Act Advance care planning for people with dementia, to ensure that the wishes of the individual are recorded, and Best Interest Decisions can be supported where appropriate. Best interest decisions and safeguarding of vulnerable people Shared approaches to care planning across organisational boundaries

24/7 Access to Services Key Local Areas to Address The interface between different health and social care organisations when people are discharged from hospital Clinical and non-clinical health and social care support for dying people, families and carers. This needs to be addressed in hospital, people’s usual place of residence (both private residence, and care and nursing homes), and the community 24/7 Overnight crisis support for people at the end of life, their families and carers Access to specialist palliative care 24/7, through a variety of methods, e.g. face to face, telephone and remote consultations.

Support and Education for Communities (including Families, Carers and Care Homes) Provision of education and training programmes for families, carers, volunteers and communities to build resilience and compassion and support Understanding the networks that can be used to outreach to communities and cascade information, raising public awareness, including the National Dying Matters campaign Understanding existing and developing local voluntary sector work and how it can form part of a joined up pathway Provision of holistic spiritual care in the community Timely access to up to date information and advice Support for carers; psychological, care coordination, and carers' assessment Developing skills of care home teams to support people at the end of life Bereavement support Support for people who are homeless to access services Support for people who do not access services through traditional routes, for example transient communities Availability of appropriate services for people with substance and alcohol misuse problems Wider access to information for those coping with a terminal illness including access to benefit advice including managing finances

Thank you