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Community referrals for End of Life care

As part of the COVID 19 discharge and admission avoidance process we have agreed an interim process for accessing additional care and support for individuals in the community with increased care needs:

Admission Avoidance and Referrals from within the community

For any cases with where the increased care needs including End of Life requiring additional care to avoid hospital admission

  • For patients known to DNs AND where the increase care needs are identified by the DN  (including end of Life needs) the DN will complete a short form assessment identifying nursing needs and care required or short version of  FT document (attached) and forward to the MLCSU CHC team for brokerage of a care package
  • Where the GP identifies that the patient is approaching the End of Life and requires additional care and support –i.e. admission to Nursing Home or a care package at home the GP can complete the short version of the FT document (the GP is not required to complete the Care prescription within the referral form the CHC team will complete this) and forward to MLCSU CHC team for brokerage of a care package. The GP should provide contact details of a nominated person/representative for MLCSU  to contact if further information regarding assessment of needs or care package is required.  The CSU will contact the individual/family (which ever contact the GP provides) to undertake a telephone Nursing assessment to determine what support/type of care – Home or NH the individual requires and broker accordingly.
  • Where a GP identifies that a patient requires additional care and support (but not End of Life) the GP can contact MLCSU (contact details below ), with patient details and the CSU will MLCSU will complete a telephone assessment and care prescription and broker care as required.
  • Where a Care Home feels that a patient is rapidly deteriorating and approaching the end of life they should contact the GP to ensure appropriate RESPECT/DNAR is in place and any anticipatory medications arranged. The Care Home can also complete the short version FT form and contact MLCSU CHC team.
  • For all other cases i.e. where a social worker identifies that an individual has escalating needs that require additional care to avoid hospital admission – patient details should be passed to MLCSU – MLCSU will complete a telephone assessment and care prescription and broker care as required.

For all patients discharged end of life from Acute Hospitals the GP will be informed by the locality DN team AND the MLCSU will, if they broker any care – Dom care or NH will also let the  GP know.

End of Life inbox for MLCSU CHC team:   mlcsu.derbyshirechcfastrack@nhs.net

Direct contact number for GPs/referrers to contact : 01332 888212 CHC SPA

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