This case study is part of a research project undertaken by The King’s Fund and funded by Aetna and the Aetna Foundation in the United States to compare five successful UK-based models of care co-ordination.
What does the service aim to do?
The service seeks to provide direct care and support to patients in the last 12 months of life to prevent unnecessary hospital admissions and enable them to live at home and die in the place of their choice.
How is the service structured?
The service is provided by a multidisciplinary team consisting of palliative care consultants, specialist nurses, health care support workers, allied health professionals and volunteers. Patients are allocated to one of six clinical nurse specialists (CNSs) ensuring continuity of care. A seventh CNS covers for others on leave or sick leave. Volunteers provide additional support through activities such as shopping or gardening. Information about patients is shared at multidisciplinary meetings held daily and weekly and logged on the internal IT system. Team members also use telephone and face-to-face communication to update each other about a patient’s status, and to liaise with GPs and community health teams.
What is distinctive compared to the standard practice of care?
The majority of patients at the end of their life tend to be treated in hospital or a hospice. Providing specialist palliative care in the community is unusual as it requires a significant level of co-ordination between professionals to ensure that all symptoms are managed effectively and that care packages are readjusted as a patient’s condition progresses. The Midhurst Macmillan Service has access to palliative care consultants based in the community who are able to provide specialist interventions that are normally delivered in hospital at the patient’s home.
What are the key lessons?
- Awareness-raising and relationship-building
The Midhurst Macmillan Service has been successful in engaging with most GPs in its catchment area, ensuring that care co-ordination and planning involves the patient’s primary care physician. The service has also built relationships with a wide range of other stakeholders, including community staff, hospital consultants, volunteers and local people strengthening its ability to ‘capture’ people nearing the end of life before, or very soon after, a hospital admission.
- Holistic care assessment and personalised care plan
A single assessment process examines both the health and social care needs of the patient and their family. It also takes into account their personal choices about future care and treatment options.
- Multiple referrals to a single-entry point
The service accepts referrals from any health professional and actively engages local GPs to raise awareness of the service. All referrals come into the service and are assigned to a clinical nurse specialist from a single-entry point.
- Dedicated care co-ordination
The care co-ordinator has a number of roles: acting as the principal point of contact with the patient and their family; effectively co-ordinating care from within a multidisciplinary team and liaising with the wider network of care providers.
- Rapid access to care from a multidisciplinary team
Both professionals and volunteers can be rapidly deployed by the service to provide care or support to meet the needs of people living at home. The service operates 12 hours a day, with access to an on-call clinician out of hours.
More information about the service
For more information, visit the Midhurst Macmillan Community Specialist Palliative Care Service website.
No. of pages: 34
See more of our work on co-ordinated care
- Watch our video to find out more about Midhurst Macmillan's approach to care co-ordination
- View our organogram showing the Midhurst Macmillan care planning/co-ordination process
- Read the Midhurst Macmillan patient stories
- Find out more about the project: Co-ordinated care for people with complex chronic conditions