Most patients prefer to have their care at home. Palliative care for patients at home is led by GPs and community nurses. Expert input, when required, is provided by community specialist palliative care teams made up of clinical nurse specialists with clinical leadership provided by consultants in palliative medicine. These expert teams are usually advisory rather than providing hands-on care although this will vary between localities. In many cases there will be shared care with GP colleagues. Access to palliative care is through referral by the GP, a hospital team or sometimes at the request of the patient and family. In the last days of life at home, this may be supplemented by hands-on care from carers provided by social services or Marie Curie (or equivalent) nurses. Some localities offer hospice at home services. These vary in what they deliver and can range from a rapid response service to provision of hands-on care in the home over a sustained period.
Palliative care is well used to delivering and influencing services in acute hospitals and community settings. Professionals are skilled in the delivery of integrated care and are able to bridge the gap between care settings which strengthens the continuity of care so important to patients and families. This integration helps to support quicker and more effective discharge from hospitals and reduce unplanned admissions. From within an acute setting, palliative care teams will facilitate earlier discharges from hospital to home.
Palliative care input provides expertise in difficult clinical situations encountered by the patient, family or attending professionals, such that hospital admission may be avoided. In some localities this is augmented by hospice at home services.
Consultant-led comprehensive community-based palliative care services, which through close integration with the GP and district nursing teams, achieve a proactive rather than reactive model of support to the patient and family where problems are anticipated, reduce the risk of crises and unplanned hospital admission. This may include MDT working where the palliative care nurse joins primary care team discussions of patients on palliative and end-of-life care registers; referrals triggered by discharge from a local acute trust rather than awaiting for urgent referrals; support for intravenous infusions and drainage of effusions at home. Examples such as the Macmillan Midhurst model (opens PDF, 2.3MB) have offered innovative 7-day services that support people effectively at home.
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