Northumberland, Tyne and Wear
Local providers, in partnership with NHS South of Tyne and Wear, are now delivering new and improved services as part of the project's integrated service model including a coordination centre, out-of-hours nursing service and discharge liaison service.
Understanding the local needs
In 2009, the project team completed a comprehensive review of end of life care services in Northumberland, Tyne and Wear involving local health and social care professionals, as well as patients and carers.
The review highlighted opportunities for improvements in:
- Communication across care settings to enable professionals to have access to and share information on patients with palliative care needs
- Coordination of care across all settings and access to care packages from different providers
- Access to community palliative care services so that they are well coordinated, flexible and responsive
- Support and information for carers to help them with their caring role
Designing and piloting new services
The project has introduced an integrated end of life care model in South of Tyne and Wear. This model enables better integration of health and social care in the acute and community settings. This ensures greater continuity in the delivery of care to patients and in the communication of information between professionals and services in acute and community care.
The Delivering Choice integrated end of life care model comprises:
- existing core services in the community including those provided by acute care, hospices, social services and out-of-hours care
- new services which are implemented as part of the Delivering Choice project including the coordination centre, out-of-hours nursing service and discharge liaison service
- the locality palliative care registerthe key worker role
The South of Tyne and Wear Palliative Care Coordination Centre acts as a central resource for arranging care packages on behalf of local health and social care professionals. It provides an administrative support service by organising palliative care packages from the most appropriate providers, as requested by professionals. The coordination centre also maintains the locality's palliative care register including information on patients' preferred place of care.
The Out-of-hours Palliative Care Nursing Service in Gateshead and South Tyneside provides an overnight nursing service to patients cared for at home. To prevent unnecessary hospital admissions, the service is delivered by practitioners with palliative care skills and expertise. Visits can be planned or in response to urgent requests.
The Marie Curie Discharge Liaison service based at South Tyneside District Hospital enables the timely discharge of patients in the last two weeks of life from hospital to their preferred place of care – home, a hospice or care home. The discharge liaison nurse facilitates a responsive and integrated approach to discharge planning involving hospital and community staff. This ensures patients have the appropriate services after their discharge.