Over 80% of our care is delivered in the community allowing people with life-limiting conditions the opportunity to stay living in their own home or in their care or nursing home. Our CNSs [clinical nurse specialists] work to achieve this by forming a vital link between home and the expertise of the in-patient care hospice setting.
The team consists of a mix of CNSs, with the support of Palliative Care Consultants, split across two sites in order to cover the communities across the North West Surrey area. They work alongside GP’s and District Nurses to ensure seamless care in the community. They visit any care setting, in patient homes, or a nursing or care home, and they accept referrals based on need rather than diagnosis. They visit patients seven days a week and to support this the hospice provides a 24 hour advice line.
Referrals are usually received from healthcare professionals. One of the community CNSs will then usually arrange a home visit. An initial visit would last approximately one hour, to make a full assessment of physical, spiritual and social needs. Urgent referrals are seen within 24 hours.
Future visits, ideally with this same nurse and co-ordination of care combined with advanced care planning where possible will then be agreed. The CNS is qualified to provide complex symptom management and psychological support in order to optimise quality of life for the patient and carers.
Further referrals will then be made to the wider team where appropriate to:
- Medical Team
- Occupational Therapy
- Counselling Team
- Daycare Service - the Wellbeing Center
- Complementary Therapy
- Spiritual Care Team
- Social Worker