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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Abstract

Introduction

Bromley 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.

Introduction

The Bromley Care Coordination Centre offers 24/7 telephone support and home visits to patients providing symptom control pain control and psychological support.

Aim

To understand patient characteristics end of life needs and BCC service response in order to refine service delivery.

Methods

Service evaluation using routine collected service data notes and case reviews.

Results

Results since Jan 2014:

Conclusions

Learning has led to working with a different skill mix developing a ‘stratification’ tool introducing the role of care navigators and volunteers.

Conclusions

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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