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

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

3. 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’

6. 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.

7. 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 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

8. 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 ed 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

9. 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 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

10. 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

11. 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