2 Learning from a new model of end of life care for older people with frailty/multi-morbidities – the challenges and opportunities for specialist palliative care services

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IntroductionBromley Care Coordination (BCC) at St Christopher’s Hospice is an innovative nurse-led community based service to enable patients with advanced illness or frailty thought to be in the last year of life to receive timely and well- coordinated care at home. Commissioned in 2014 by Bromley CCG reaches people who would not traditionally be seen by hospice community care teams.The Bromley Care Coordination Centre offers 24/7 telephone support and home visits to patients providing symptom control pain control and psychological support.AimTo understand patient characteristics end of life needs and BCC service response in order to refine service delivery.MethodsService evaluation using routine collected service data notes and case reviews.ResultsResults since Jan 2014:2200 people have been referred (55% from GP 26% from Hospital 19% other)Of those who have died 70% have died in their own home/care homeAverage age of patients referred 86The ratio of non-cancer to cancer diagnoses is 85%: 15%86% of patients have no other current health care intervention apart from the GP and occasionally a social care agency/provider (16/17 data)39% of patients live alone many more patients live with a spouse who is also frail and elderly.ConclusionsLearning has led to working with a different skill mix developing a ‘stratification’ tool introducing the role of care navigators and volunteers.BCC has extended the hospice’s reach by 50% in one CCG. The next stages are embedding sustainability and implementation in other areas.

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