Neighbourhood Hubs referrals

REFERRAL CRITERIA

Aim of the Service

To achieve the best quality of life possible for patients with a palliative or terminal illness or advanced progressive disease, centred on their goals, in a non-clinical environment nearer to people’s communities, and to support their carers. To have physical, emotional and spiritual issues addressed, including discussing advance care planning where patients can detail how they want to be treated and cared for going forward.

The primary aim of the Neighbourhood Hubs is to provide rehabilitative, non-pharmacological and psychosocial intervention and support to empower patients and carers to:

• Understand their condition.
• Self-manage their symptoms using non-pharmacological strategies.
• Remain as independent as possible within the limitations of their illness.
• Maintain participation in meaningful activities and achieve realistic goals that add quality to life and improve function.
• Maintain and/or improve global quality of life.
• Remain at home or in their preferred place of care.

Referrals are accepted from any health or social care professional involved in their care.  Patients and carers can also self-refer to the service. For all accepted patient referrals, supporting information will be requested from their doctor and/or medical consultant and the GP will be informed.

Service structure

The Neighbourhood Hubs services are delivered by the therapy team, working in partnership with the community engagement team and volunteers. The service is managed by the therapy and community services manager. ALL Neighbourhood Hubs services are subject to the patient meeting the referral criteria set out below.

Services offered

Patients and carers would normally have the option of being seen as an outpatient at either of our hospices or in an outreach facility. However, during Covid-19 restrictions, all appointments are by telephone or video call. This will be discussed with the patient and/or carer and agreed as to where/what would be the most suitable and appropriate mode of contact.

The Neighbourhood Hubs Services include:

One-to-one outpatient therapy appointments (face to face or telephone/video) for assessment and treatment by physiotherapy and occupational therapy. In view of the general aims of the service focusing on rehabilitation, education and empowerment, patients/carers are offered a set number of 6 sessions per specialty. However, if patients/carers’ needs change during this time, additional sessions may be offered subject to approval by the therapy manager.

Home visits may be conducted for environmental assessment purposes or in exceptional circumstances but the Neighbourhood Hubs are not home-based services so housebound patients will be referred/signposted to other services in the community.

In development: Educational / Condition management workshops, aimed at empowering patients by providing information, education and practical tools for patients to manage their condition and symptoms. Topics covered will include: Fatigue management, breathlessness management, advance care planning, managing practically at home, relaxation and coping with worries, staying fit and well. Patients will be able to attend whichever workshop they feel is relevant to them, up to twice (priority will be given to those who have not yet attended). We would be interested to hear from you if you have ideas on what you might find useful in a workshop.

In development: Bereavement support workshops/group led by OT and Cruse-trained Community Engagement Officer. The aim is to provide information, practical tools and psychological support for bereaved carers and prevent social isolation. It may include learning skills for independent living, transitioning to living without their loved ones, creating new routines and new activities, sharing tips with others in a similar situation, using creative activities as a support to conversation etc. Again, we would be interested to hear from you if you have ideas on what you might find useful in such a workshop or group.

Aside of the Neighbourhood Hubs, the Cornwall Hospice Care Community Services offer a Listening Ear service and Community Friendship Café (currently on facebook), which is also available to Hubs patients/carers.

General principles of referral

For the purpose of this document referral means a contract between any healthcare professional or patient directly, and the therapy led Cornwall Hospice Care Neighbourhood Hubs.

Initial referrals will be accepted from any Health or Social Care Professional as well as the patients or carers themselves.

Information will be sought from the patient’s GP and from recent hospital notes prior to any treatment commencing to ensure it is appropriate.

Professional referrers and GP will receive a copy of the referral acceptance letter sent to the patient so that they are aware of the Neighbourhood Hubs’ involvement.

All referrals and contacts between Cornwall Hospice Care Neighbourhood Hubs and the referrer must be documented on the appropriate system or referral form. This forms a record of the service provided by Cornwall Hospice Care Neighbourhood Hubs for the purposes of governance, education and audits.

Criteria for referral

• Patients/carers must be aware of and consent to the referral.
• Patients may be referred who have been diagnosed with a palliative or terminal illness or advanced progressive disease – meaning those whose disease has been determined to be for palliative management; who may be transitioning from active treatment to palliative care; who have severe or end stage disease; or who have an advanced progressive condition. This includes diseases such as cancer, heart disease, neurological diseases and lung disease as well as other terminal- illness, from which a patient will not recover.

and have:

• Issues with difficult symptoms for example breathlessness, fatigue, reduced mobility, pain, nausea, difficulty in participating in Activities of Daily Living (ADLs) or accessing and engaging in their ‘community’ where the symptoms are severe, persistent or complex
• Psychological issues related to illness such as depression, anxiety, stress, low mood and loss of motivation
• Spiritual issues such as adjusting to the meaning of diagnosis/prognosis and disease progression
• Difficulties managing activities of daily living and accessing equipment to assist with the issues
• Complex family issues and distress as a result of / or exacerbated by current illness
• Social isolation due to illness and where other centres are not able to offer palliative expertise
• Rehabilitation needs following treatments and/or diagnosis
• Difficult issues related to making decisions and planning for the future
• Carers who need additional support as a direct result of the current illness
• Non-palliative Cornwall Hospice Care Lymphoedema patients who need therapy input in order to facilitate lymphoedema treatment.
• Inpatients discharged from one of our hospices who need further therapy involvement to support their function at home or in support of imminent anticipated deterioration.

• Carers may be referred who care for a patient meeting the above criteria (excluding non-palliative lymphoedema patients). This does not include formal/paid carers.
• Patients and carers must be 18 years of age or over and live in Cornwall in their own home.
• Patients should have unresolved, complex needs that cannot be met by the current caring team, or it is anticipated that the patient will develop such needs in the near future. These needs may be psychological, social, spiritual or physical.

Inappropriate referrals

• Under 18 years of age.
• Referrals for patients out of county.
• Conditions not meeting the above criteria.
• Patients with chronic clinically stable disease or disability, or long-term conditions (i.e. a disease that persists over a long period and is neither decreasing nor increasing in extent or severity) with a life expectancy of several years.
• Patients with chronic pain problems not associated with progressive terminal disease.
• Competent patients who decline referral or who are unaware of their underlying disease.
• Those whose problems are principally psychological and need specialist psychiatric referral, whether or not they have declined such help.

Response to referral

• All referrals will be triaged by a community services allied health professional to ensure the person meets the criteria and that we can offer a service pertinent to their needs.
• Patients and carers will be sent an information pack by post (or email if they prefer).
• Patients will be contacted by the allocated therapist or a therapy assistant within seven working days of receipt of the referral. This may be a telephone call, email or letter.
• Patients will be sent an assessment of needs and priorities questionnaire with the pack. Once returned, the questionnaire will be reviewed by a community services allied health professional to establish whether other therapies or services would benefit the person. For more urgent cases, the questionnaire can be completed over the phone.
• All patients and carers will discuss a “plan of care” with their therapists from the outset. This will include the number of sessions available, how to space them out and planning for discharge from the therapist’s care once goals are achieved.
• All patients’ and carers’ needs and plan of care will be reviewed regularly. Not all sessions may be required. If additional sessions are needed (for example because the person’s condition worsens or significant events occur) this must be discussed with and agreed by the therapy manager.