Community Integrated Palliative Care Team
The Community Specialist Palliative Care Team has been developed from an integration of two palliative care services, previously known as Community Macmillan Nurses and Hospice at Home.
The service aims to be more responsive to patients’ needs by providing seven day specialist palliative care advice and expertise, with Specialist Palliative Care Triage, and seven day community visits.
We recognise the palliative care skills already provided by the Primary Care Team. Not all patients with a malignant disease or life threatening illness will require intervention from the Community Specialist Palliative Care Team. The primary care team are often best placed to identify when they need help with a palliative care patient.
Referral should be with the patient’s consent and made for:
Patients with complex symptoms where
- The district nurses and the GP have attempted to manage the symptoms without success.
- The patient has been discharged from hospital or the hospice with known complex symptoms that have required the help of the specialist palliative care team during the inpatient stay.
- Attempts have been made by generalist staff, for example, at outpatient clinic, to manage symptoms before referral to the specialist palliative care team.
Patients and their relatives/carers requiring specialist information at the time of diagnosis of progressive disease or recurrence. This would be in addition to the palliative care information and support provided by the general primary care team. It would also be in addition to the information and advice provided by hospital teams.
Patients and their relatives/carers requiring additional specialist palliative care social, spiritual and psychological support over and above that provided by primary carers, where there are assessed complex needs.
In addition we are able to offer patients and families requiring more palliative input and support to facilitate remaining in their preferred place of care by the provision of enhanced support. Care will be predominantly provided by healthcare assistants, supported by the Palliative Care staff nurses within the team. Patients will have palliative care needs but additional care is required to support existing community services.
- Uncontrolled symptoms, requiring close monitoring in partnership with the Community Specialist Palliative Care Nurses if appropriate
- Rapidly deteriorating condition, resulting in the need for more support.
- Carer unable to cope with changing/unpredictable demands in patient care, where the ceiling of care has been reached with existing community services.
- Breakdown in care will lead to an in-patient admission and a significant step up in care is required to support the patient and carer to remain in their preferred place of care
- Rapid discharge from in-patient settings where Preferred Place of Care/Death is identified as patient’s own home and additional care is required to support existing Community Services.
- Patients living alone whose preferred place of death is their own home
If input is required up until the time of death, the carer will be offered a post bereavement contact and assessed for specialist bereavement support. Referral to further bereavement support will be made if required, and then the carer will be discharged from this service.
Referrals to the Specialist Palliative Care Team need to be made via the new referral form and fully completed with attached additional information as appropriate.
The service can be contacted by:
- Phone: 01302 566666 (advice)
- Fax: 01302 566665 (referral form)
- Tasks can be sent via TPP to SPC Triage task group (referral form saved in Communications and Letters)
- Email referral form
These numbers / emails are monitored :
Monday to Sunday – 8.30am to 4.30pm
Main Contact Details:
St John’s Hospice, Weston Road
Woodfield 24 Care Services
Woodfield 24 Care Services’ staff provide personal care to people in their own homes as they approach the end of their lives. Acting on referrals from healthcare professionals, the Woodfield 24 Care Services staff will be called in – often at very short notice – to provide care and support to those who want to die at home rather than at hospital or in a hospice. They will go into patients’ homes and help out with everyday household needs, working as a team alongside district nurses and other community staff.
St Catherine’s House
Telephone: 01302 798000