Palliative Care Clinical Care Programme

Slides:

Advertisements

Similar presentations

Implementing the Stroke Palliative Approach Pathway

Advertisements

Lori Embleton, Program Director WRHA Palliative Care Program

Routine postnatal care of women and their babies

Care Coordinator Roles and Responsibilities

Early Intervention Memory Service Norfolk and Suffolk Foundation Trust (NSFT) has been commissioned by Ipswich and East Suffolk CCG to establish and run.

Strengthening Community Mental Health Services – Acute Care Pathway Redesign Consultation Briefing for Bolton Health, Care and Wellbeing Forum 10 th February.

GOLD STANDARDS FRAMEWORK

Whats wrong with a piece of paper? The Electronic Transfer of Care Princess of Wales Hospital Rowena Lewis.

GP Link Program Susan Davis Clinical Nurse Consultant GP Clinical Liaison Officer (GPCLO)

Rapid Admission of Palliative Patients. Hospital Macmillan Specialist Palliative Care Nurse. Lung Cancer Specialist Palliative Care Nurse. September 2008.

Integrated Services Dr Steve Cartwright – Clinical Executive for Integration and Partnerships Andrew Hindle - Commissioning Manager for Integration.

Pathways 4 Life Presentation by: Davina Lytton, Kelly Davis & Michelle Ebanks.

Baseline Model of care for proposed community wards Appendix 1.

Enhanced SPARRA Predictive Model & SPARRA Patient Alerts Risk prediction and service development Kathleen McGuire – Long Term Conditions Manager Ehealth.

DISTRICT NURSE LIAISON DEPARTMENT RLI. Learning Outcomes Focus on discharging planning An overview of our role Discharge process at the RLI Increased.

Role of the Integrated Specialist Palliative Care Team Juliet Cross – Palliative Care CNS (community) Sara Smith – Nurse Practitioner- End of Life Care.

Acute Medicine Programme A clinician-led initiative of the Royal College of Physicians of Ireland (RCPI), the Irish Association of Directors of Nursing.

Implementing the Single Assessment Process across the South West Peninsula Basic awareness.

Sandra Petrie Clinical Screener Care Coordination.

Information for Decision Makers Acknowledgement: Adapted from Liverpool CCG, with kind permission.

RAPID DISCHARGE PLANNING – GETTING A PATIENT HOME Jacqueline O’Brien MSc CNM2 Palliative Care Beaumont Hospital.

Frail Older People Co Chairs Maura Devlin and Dr April Heaney Engagement through a workshop with a wide range of stakeholders Key priorities areas identified.

Royal Wolverhampton Hospitals NHS Trust Medical Staff Induction Day Palliative Care at New Cross Hospital Dr Clare Marlow Dr Benoît Ritzenthaler Consultants.

Importance of end of life education for all Rachel Burden.

Addenbrooke’s Hospital Rosie Hospital Caring for Patients in their Last Days of Life Dr Douglas Maslin (ACF CMT1) and Dr Kate Kiln (CMT2) Supervisor: Dr.

Hertfordshire: Working together in preparation of Winter 2013/14 Hertfordshire County Council.

Discharge planning – reducing admissions/readmissions Jo Clarke, CPPE tutor 1.

The West Midlands Children and Young People’s Palliative Care Toolkit Lynette Thacker Clinical Nurse Specialist Paediatric Palliative Care ABMU Health.

Sharon Cansdale GSF Facilitator Gold Standards Framework in care homes.

The London Older People Service Development Program (LOPSDP) The ‘Medicines Management’ Project (January to July 2003) Lelly Oboh Project Co-ordinator.

Service 19 TH JUNE 2014 /// SEPTEMBER 4, 2015 ALISON CLEMENTS.

Outreach Team Presentation By Shannon Skerratt and Denise Chambers.

Induction : 2012 End of Life Care. Introduction Discussion of EOLC may stir up unresolved bereavement issues – personal or professional. Discussion of.

Satbinder Sanghera, Director of Partnerships and Governance

CRISIS MANAGEMENT AT THE MANAGED CLINICAL NETWORK.

Safe Transitions Of Care STOC 2011 MHA Pilot- 4Q 2010 Transition responsibility belongs to the sending clinician/organization, until the receiving practitioners.

Sharon Cansdale GSF Facilitator

The PAN-Care Project Development and testing of a comprehensive care planning service to enable patients with end stage pancreatic cancer die at home Department.

Community Nurse In-reach (CNIR) Providing safe & effective nursing discharges across the Hospital & Community Interface.

Report out 1 st July 2009 Palliative Care RIE Ward 3 Ninewells Hospital.

End of Life Care At the West Suffolk Hospital

Electronic Palliative Care Summary (ePCS) Dr Peter Kiehlmann GP, Aberdeen & National Clinical Lead Palliative Care eHealth

Corporate objectives ~Improving patient safety and the patient experience ~ supporting key national targets ~ Improving partnership working Supporting.

Community Intervention Team – the role it plays in integrated patient centred care Noreen Curtin 6th October 2015.

Islington Additional Needs and Disability Service (IANDS) - Therapies Sally Fraser: Clinical Lead Speech & Language Therapist in Mainstream Schools Shonali.

MAKING CARING CONNECTIONS CONTINUITY OF CARE TRANSFER PROJECT Staff Education Presentation Hospital Presenter’s Name Date.

Holistic Assessment Rapid Investigation

Implementing the Single Assessment Process across the South West Peninsula Basic awareness.

Discharge Pathway Preparation for admission Hospital ward to make contact with the person as far in advance as possible so that arrangements can be made.

Level 6 Discharges from Bradford Teaching Hospitals: Destination and Survival Dr Kath Lambert SpR in Palliative Medicine BRI.

Best Practice in End of Life Care:

Name of presentation Improving health in Greenwich: Linking integrated health & social care with primary care.

Readmissions Driver Diagram OHA HEN 2.0. Readmissions AIMPrimary Drivers Secondary DriversChange Ideas Reduce Readmissions Identify patients at high-risk.

Review of the Peninsula Health Hospital Admission Risk Program (HARP) Presenter: Belinda Berry PENINSULA HEALTH COMMUNITY HEALTH.

INTENSIVE SUPPORT TEAM A New Way Forward. PREVIOUS SITUATION The average length of stay for a person in an Assessment and Treatment Unit was up to 18.

Gold Coast Health Service District Introduction to Palliative Care Services Ingrid Skilton – Clinical Nurse Consultant Katherine O’Shea – Senior Occupational.

The NSW Resuscitation Plan- Paediatric Information for Health Professionals.

Discharge planning Discharge Liaison Nurse’s Patient Flow Team Janet Davies Christine Jones-Williams.

Pathway of care for people with learning disabilities Consent to treatment Does the person have the capacity to consent? Can the decision wait until the.

End of Life Care- Finding your 1% Julie Foster End of Life Care Lead Cumbria and Lancashire EoL Network.

PATIENT & FAMILY RIGHTS AT DOHMS. Fully understand and practice all your rights. You will receive a written copy of these rights from the Reception, Registration.

Introduction to the Gold Standards Framework Domiciliary Care Training Programme Maggie Stobbart-Rowlands, Lead Nurse, GSF Central Team.

Children and Families Division Who are we? We are a skilled Team of Doctors working with children from birth to school leaving age, across the city of.

A Palliative Care Resource Scheme

Developing a Transitional care Service within Perth City

Medication Reconciliation ROP Compliance

Discharge Pathway DRAFT Admission into Hospital

Occupational Health Management Referral Guide

Improving Pain and Symptom Management

Neuro Oncology Therapy Update

Presentation transcript:

Palliative Care Clinical Care Programme Rapid Discharge Planning Pathway Palliative Care Clinical Care Programme

What is the aim of RDP? To facilitate a safe, smooth and seamless transition of care from hospital to community for persons who have expressed a wish to die at home. Published 2013 Version 1

What is the rationale for rapid discharge planning (RDP)? Driven by the wishes of the person and their family/carer. When a clinical situation has changed and there is an urgent request to enable the person to die at home. Part of HSE Integrated Discharge Planning. Published 2013 Version 1

What is the purpose of the RDP document? To: Support the wishes of the person and their family/carers. Provide a framework for collaborative working across primary and secondary care. Support effective communication between all key stakeholders. Facilitate the involvement of appropriate professionals to coordinate the continuing care. Published 2013 Version 1

Who does the RDP involve and concern? All health and social care professionals working in the HSE and in any organisation providing services on behalf of the HSE. People affected by the guidance i.e. service users and their families/carers, and the general public. Published 2013 Version 1

What are the steps in RDP process? The Person chooses to die at home Step 1 Step 2 Doctor confirms it is appropriate and the Family/ Carer support CNM identifies Lead Nurse to coordinate Step 3 Lead Nurse implements process Step 4 No anticipated post mortem or organ donation Lead nurse leads on implementation of RDP action plan Doctor documents in person’s notes Lead nurse identified from person’s ward/unit Published 2013 Version 1

What does the Lead Nurse do? Contact GP, PHN/DoN and other members of the primary care and/or specialist palliative care team as soon as possible. What does the Lead Nurse do? Contingent on certain supports/ services Poses a clinical risk to safety or well-being The GP and PHN /DoN: may confirm that rapid discharge is appropriate Rectify and proceed or Rectify and proceed or Proceed with plan Unable to rectify, abandon and discuss with patient, family and team Published 2013 Version 1

What are the next arrangements to implement? Within 24 hours before discharge: Ambulance Liaise with Ambulance Service re: Transport arrangements Ambulance letter Primary Care Team Liaise with GP/PHN/DoN Develop care plan Liaise with MDT Fax copy of prescription to GP & community pharmacy Equipment Organise equipment Medical supplies Write nursing discharge letter Family Support family Clarify expectations Provide carer education Published 2013 Version 1

Liaison with Hospital/Community MDT Physiotherapy Dept: As appropriate Medical Social Work Dept re: Assessment and addressing of psychological needs Essential practical needs Community Pharmacy re: Unlicensed meds Meds difficult to source Meds not on GMS OT Dept re: Essential equipment Published 2013 Version 1

What are the considerations when planning with CNS in Palliative Care? Is Night Nursing Service required? Is Community Specialist Palliative Care Team (SPCT) required? Advise re complex needs for potential symptoms Published 2013 Version 1

What is the role of the NCHD in RDP planning? The NCHD will: Write discharge letter. Write prescriptions - regular medications/p.r.n. medications (24 hours prior to discharge). Contact GP re verifying and issuing the certificate of cause of death. Complete section in ambulance service letter. Published 2013 Version 1

What are the Final Actions? On discharge: Letters to: GP, PHN/ DoN SPCT Other member of the primary care or specialist teams as appropriate. Letter to Ambulance Service including DNAR order as appropriate. Syringe pump: Change immediately prior to discharge if in use. Prescriptions: Hand to family unless transferring to residential care facility. SPCT GP PHN /DoN Ambulance Published 2013 Version 1

What information can I find in the RDP Document? Detailed outline of rationale and process. Outline of roles and responsibilities. Information regarding actions when anticipated post mortem is anticipated or agreement for organ donation. Useful links to resources. Useful suggested templates and flow-chart of process. Frequently asked questions. Published 2013 Version 1

Please visit: www.hse.ie/palliativecareprogramme to download RDP document and for further information on the HSE Palliative Care Clinical Care Programme. Published 2013 Version 1