Integrated care – making positive impacts when it matters most

Abstract

We have been working together in a blended way with a common vision to ensure palliative and end of life care services provided in the home setting, inclusive of care homes, truly makes a difference to people known to be palliative – regardless of the stage of their disease. Our integrated, 24/7 rapid responsive care service, is not defined by an illness time point.

Our vision was to provide an enhanced specialised team together. This team would do their utmost to ensure that any calls for help resulted in people remaining being cared for in their own home setting wherever possible – a wraparound service, ultimately avoiding unnecessary acute care admissions.

Patients, family members, friends or professionals simply have to dial our direct mobile number and circa 90% of those calls for help will receive a visit from our team in person within 30 minutes of making their call overnight, 365 days a year.

In the first full operational year (2018-19) of the service, 823 patients received 1479 visits between 8pm-8am. As the service extended to 24 hours in 2020-2021, our visit count reached 3628, with only 16 of these visits resulting in an acute admission for clinical need. Our team reported that 2216 of the 3628 visits, without their input, most likely the outcome would have been transmission to local A&E.

In addition to people being able to receive care where they prefer to; our service costs us between £50-60 per hour to provide – considerably less than an onward ambulance journey and potential acute hospital admission.

Working as a large NHS Foundation Trust – over 5000 employees and a small independent charity community hospice with just over 60 employees brought us several challenges as well as benefits. The benefits of integration for our local population have by far outweighed any challenges which we overcame together and will continue to do so going forwards.