To describe the development of a model of an integrated, consultative, palliative care approach within a comprehensive chronic heart failure (HF) communication-focused disease management program.
The model has four areas: diagnosis and secondary prevention; rehabilitation and promotion of self-care strategies; reinforcement, monitoring, and community coordination of care; collaborative palliative care support of families. Education and training in end-of-life physical symptoms and emotional and ethical issues; palliative care approach.
Communication between teams was improved. Division of GP has been pivotal in developing the model by endorsement of the model and provision of educational activities and dissemination of communication.
To describe and evaluate short-term specialist palliative care at home.
A 72-hour community palliative care nursing service to patients moving between in-patient and community care includes 24-hour care; responds to specialist palliative care needs within the community setting; provides short periods of specialist care; allows for a preadmission assessment; provides a short period of intensive support to try and prevents admission; facilitates access to 24-hour inpatient beds; enables a rapid discharge from hospice/hospital setting; enables a patient to die at home.
In-house audit examined records of all patients referred during the first year (); and 55 questionnaires to healthcare professionals in the locality, 27 returned (respond rate = 49%).
The service responded to patients’ needs quickly with expert support.
To describe the evolution of joint working between heart failure specialists (HFNSs) and specialist palliative care services in Bradford.
HFNS attended the community palliative care team’s regular multidisciplinary team meetings (MDTs); formal education by the palliative care service and vice versa; practice-based education for primary care staff by HFNSs and consultant. Collaboration over patient care: telephone advice; joint case discussion and visits with a Macmillan nurse; medical assessment at a hospice-based outpatient clinic; hospice admission for symptom control or terminal care. A Heart Failure Support Group (HFSG) for patients and relatives.
Data collection, audit, and evaluation performed by the Heart Failure Nurse Specialist (HFNS) and palliative care service: a shared electronic clinical record system; recorded key information on a database; data from the patients’ paper records; qualitative data on 15 patients’ experiences of the support group.
The HFSGs help patients to cope in key areas such as: physical, psychological, and social isolation; loss of self-esteem and sel-worth; generating hope and purpose. The HFNSs can function as key workers, providing support throughout the illness and maintaining continuity of care. Few patients have needed direct care from the specialist care service.
To evaluate the impact of a new post, where 20% of a clinical nurse specialist’s (CNS) full-time post was dedicated to working between three palliative care teams in Manchester.
The time was used on visiting patients on the wards; nurse specialists accompanied the CNS in patients’ homes; contributing to an audit tool; joint teaching sessions; developing palliative care concerning end stage renal failure; providing a link between patients’ community and hospital to exchange information; initiate a referral.
Progress in improving communication and collaboration between the teams was noticed. Opportunity to follow patients. More detailed history of the patients’ care. Further recommendations: monthly and bimonthly interprofessional meetings (face-to-face dialogue); shadowing colleagues in practice; joint educations sessions.
To discuss the lack of equity of palliative care for patients with heart failure and what a hospice Macmillan clinical nurse specialist (MCNS) team sought to achieve by working collaboratively with their community heart failure nurse specialist (HFNS) colleagues.
Education of HFNS and MCNS. The referral criteria as developed by Merseyside and Cheshire Specialist Palliative Care and Cardiac Clinical Networks were adopted. Standard referral forms were used to monitor referrals to the service and track outcome. HFNSs remain key worker, using the MCNS as a resource. HNFS and MCNS undertook joint assessment visits at the patients.
Open and honest communication between professionals and the families. Joint visits ensured that that HFNS and MCNS worked outside their own professional competence and enabled new learning to take place.
To support community matrons in their care of patients at the end of life through the creation of a new model of collaborative working.
Pathways to clarify decision making were developed into a guide/model for use by health or social care/professional care for any patient irrespective of diagnosis. The model was based on the Gold Standards Framework (GSF), Advance Cancer Planning (ACP), and Liverpool Care Pathways (LCP).
The model helped the community matrons and nurse specialists to ensure that patients and families received optimum care and contributed to understanding of the role of palliative care in supporting patients and families.
To examine/review the impact of the GSF on general practice systems and procedures in primary care; GSF providers (i.e., the healthcare practitioners delivering the GSF, GSF users (i.e., patients and carers).
The GSF improves general practice processes, coworking, and the quality of palliative care, but can be undermined by lack of shared commitment. GSF had a positive impact on control of symptoms, continuity, continued learning, caregiver support, and the caregiver in the dying phase. Many practices are able to implement the foundation level of the GSF. However, adoption of the higher levels of care is more variable. The GSF requires adequate resources. The direct impact on patients and carers is not known.
GSF has considerable potential to improve end-of-life care, but further work is needed to support uptake and consistency of implementation. Additional evidence about patient and carer outcomes will add to existing insights.