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.