Aim of the Service
To achieve the best quality of life possible for palliative patients and their carers, centred on their goals, in a non-clinical environment/‘one stop shop’ nearer to people’s communities, and to support their carers. To have both physical and emotional issues addressed, including discussing advanced care planning where patients can detail how they want to be treated and cared for going forward.
The primary aim of the outreach service is to provide rehabilitative, non-pharmacological and psychosocial 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. In all cases the GP will be informed, and supporting information will be requested from their doctor and/or medical consultant.
Patients and carers will have the option of being seen at either a hospice as an outpatient or in an outreach facility. This will be discussed with the patient and/or carer and agreed as to where would be the most suitable and appropriate place to be seen.
1: General Principles of Referral
Patients must give informed consent to the referral.
This may include any patient:
- whose disease has been determined to be for palliative management.
- who may be transitioning from active treatment to palliative care.
- who has severe or end stage disease.
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.
For the purpose of this document referral means a contract between any Healthcare Professional or patient directly, and the therapy led Cornwall Hospice Neighbourhood Hub.
Initial referrals will be accepted from any Health or Social Care Professional (it is the responsibility of the referrer to ensure the GP is informed).
Patients or carers can make the initial contact with Cornwall Hospice Care therapy services, but contact will be made with their GP prior to any treatment commencing to ensure it is appropriate. The patient or carer can also re-refer themselves in the future if they are already known to the service should they need further interventions/treatments. They will be triaged and assessed to ensure a further episode of care is appropriate.
All referrals and contacts between Cornwall Hospice Neighbourhood Hub and the referrer must be documented on the appropriate paperwork or referral form. This forms a record of the service provided by Cornwall Hospice Care Neighbourhood Hub for the purposes of governance, education and audits.
Patients may be referred who have been diagnosed with a terminal illness and have:
- Issues with difficult symptoms for example pain, nausea, breathlessness, fatigue, reduced mobility, 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 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
3: Appropriate Referrals
- Over 18 years of age.
- Referrals will be accepted for patients with active, progressive and potentially terminal illness living in Cornwall.
- Support for Informal Carers of patients who meet the above criteria.
- 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.
- Patient or carer to be aware of the referral and consents to it.
4: Inappropriate Referrals
- Under 18 years of age.
- Out of county referrals.
- Non palliative conditions.
- 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 and patients/carers will be contacted by telephone to organise the first mutually convenient appointment, and where they should be seen. If time allows before the appointment a letter confirming this will also be sent to the patient.
- Patients will be contacted within three working days of receipt of referral.
- Patients will be invited to attend for an assessment to discuss their needs. Following this a decision will be made with the patient on what therapies and treatments may be helpful.
- All patients will have their needs reviewed after six sessions of treatment and regularly thereafter.
- All carers will have their needs reviewed after three sessions of treatment and regularly thereafter.
Patient/ Carer direct access or self-referral
Patients and carers who meet the criteria above can visit the hubs to consider if they would benefit and like to access the services on offer. A referral will be taken and submitted for triage, and the GP contacted directly by the Cornwall Hospice Care Neighbourhood Hub staff.