Needs and Resources Profile CP3 DNACPR Audit completion and quality of DNACPR documentation. March 2015 Thelma Bench Ian Marshall Gillian Robb Sandra McConnell Brian Polding-Clyde Audit complete CP4 DNACPR Monitor results of local and national audits. September 2014 and ongoing Gillian Sherwood Annual feedback to Palliative PIG with results of local/national audits CP5 Preferred place of care Clarify how preferences regarding place of care and place of death are recorded and shared between different services. September 2014 and ongoing Ruth Ward Jill McKane Annual feedback to Palliative PIG CP6 ACP Continue to support and monitor the implementation of Advance Care Planning (ACP). September 2014 and ongoing All Gillian Sherwood Moira Brown Annual feedback to Palliative PIG CP7 ACP Ensure that palliative care is represented on the newly formed CHCP steering group for ACP, and that the decisions of the group are fed back to the Palliative PIG. Ongoing Thelma Bench Christine Hennan Brian Polding-Clyde Quarterly feedback to PIG CP8 ACP Increase the number of ACPs to facilitate preferred options and record outcomes. March 2015 All There is a increase in ACP use as evidenced in the Needs and Resources Profile CP9 Anticipatory prescribing and supply Support the continued operation of the Macmillan Pharmacist Facilitator project. Ongoing Macmillan Pharmacist Facilitators Annual feedback to Palliative PIG CP10 Care management Support the transition to a named key professional for each with palliative care needs. September 2014 Thelma Bench Joyce Allan PIG members are involved in discussions at
DOMAIN 6: CARERS AND OUR COMMUNITY (CC) Action Subject Proposed action Timescale Lead Indicators of success CC1 Information about services Update and widely distribute the Inverclyde Directory of Palliative Care Services and consider using electronic media to disseminate this information. September 2014 Your Voice Stuart Milligan Directory has been updated and widely disseminated CC2 Information about services Scope the access to and use of ALISS/MILO by people with a life-limiting illness and/or their carer(s). March 2015 Christine Hennan Scoping exercise complete and report disseminated CC3 Information about services Consider how people with palliative care needs (or their carer) who also have cognitive impairment can be made aware of support available through the Carers Centre. December 2014 Your Voice Actions and responsibilities agreed upon and passed to relevant agencies CC4 General carer support Consider how additional proactive support might be made available to carers at weekends. March 2015 Thelma Bench Alison Bunce Anne Mills Meetings have taken place with relevant parties and a plan of action agreed CC5 General carer support Collaborate with Inverclyde Carers Development Group to identify and plan to meet the needs of carers of people with a life-limiting condition. March 2015 Your Voice Actions and responsibilities agreed upon and reported back to the palliative PIG CC6 Public engagement Collaborate with Inverclyde CHCP Advisory Network to identify and plan to meet the needs of service users and carers of people with a life-limiting condition. March 2015 Your Voice Actions and responsibilities agreed upon and reported back to the palliative PIG CC7 Carers at IRH Monitor carer/family satisfaction with support in IRH and March 2015 Ian Marshall Audits completed
DOMAIN 7: COLLABORATION AND CO-ORDINATION (CCo) Action Subject Proposed action Timescale Lead Indicators of success CCo1 Sharing of information Utilise immediate discharge letters (with ACP information and request to update KIS/NHS24) to ensure that awareness of preferences and values of patients/families are shared properly between the various teams and agencies June 2014 Ian Marshall Immediate discharge letters are in use CCo2 Gold Standards meetings Support GP practices to review the membership, frequency and focus of their Gold Standards Framework meetings to ensure that they are multi-professional, include patients with non-cancer palliative care needs and meet regularly. March 2015 Jill McKane Ruth Ward GSF meetings CCo3 Integrated community services Hold a facilitated workshop to examine ways of a more integrated approach to palliative care patients in the community. Complete Jackie Chaplin Workshop has taken place and report has been disseminated CCo4 Integrated community services Investigate the possibility of developing an integrated community team that adopts a proactive approach to meeting the needs of patients with life-limiting conditions in the community. March 2015 Thelma Bench Joyce Allan Anne Mills Sandra McConnell Meetings have taken place between all parties CCo5 Integrated community services Monitor and support moves to create a Transformation Champion post or similar. March 2015 Anne Mills Beth Culshaw Thelma Bench Proposal is agreed upon CCo6 Integrated community services Monitor the on-going review of the home and out-patient services at Ardgowan Hospice and support plans to achieve greater integration with primary care services. December 2015 Thelma Bench Joyce Allan Anne Mills Sandra McConnell Quarterly feedback to Palliative PIG. CCo7 Integrated community services Support improved links between (and understanding of) services (e.g. Home Care and hospice community CNS team). September 2014 Christine Hennan Anna Forde Joyce Allan Development Group set up. Hospice and Gerontology nurses attending CCo8 Information quality, Support efforts to resolve any issues with ePCS and KIS to enable them to be used optimally and accessed by all June 2015 Beth Culshaw Thelma Bench All relevant settings report having
completeness and accessibility appropriate agencies. Anne Mills Jill McKane satisfactory access to ePCS CCo9 Liaison with Site-Specific teams Continue liaison between specialist palliative care and cardiac, renal, dementia, learning disabilities, liver failure and respiratory teams. March 2015 Sandra McConnell Ian Marshall Joint education events have taken place. Joint services have been developed where appropriate. CCo10 General communication Improve communication and transparency between all areas highlighting importance that it is not one way. Ongoing All All areas report satisfactory communication