Referral to the Community Specialist Palliative Care Team (CPCT)
The community palliative care service will link with patients who require specialist support at home. A patient’s home may be their own home, a nursing home, a hostel, community hospital or family member’s home.
Our specialist community palliative care service includes:
- Palliative day services: Outpatient clinical reviews: onsite or ‘virtually’, by video call.
- Palliative day services: Single therapy appointments with a member of the multidisciplinary team (such as nurse, physio, MSW, OT or medic).
- Home visits by the community palliative care team (CPCT)
- Breathlessness Management Support Service, in Harold’s Cross
Over time, a patient’s care might move between different arms of the community service. This depends on their needs: how they are feeling; their mobility; their personal goals and other hospital appointments. But the team looking after them will be the same and works closely together.
Triage of referrals to CPCT
Referrals are coordinated to all aspects of the community services, under one referrals system. All referrals are triaged daily by the clinical team.
Our aim is to:
- Assess all patient referrals and offer a response in a timely manner.
- Enable staff to prioritise care according to need.
- Facilitate the delivery of specialist Palliative Care in the setting that is most appropriate to each patient’s needs.
- Offer support to community healthcare professionals.
The aim is to identify and quantify the need for SPC intervention. Contact is made with the patient, and the service deemed most appropriate is offered, based on the information presented on the referral form. Those who need assessment at home will be prioritised for a home visit. Those who are mobile and able to attend as an outpatient may be invited to attend a specialist clinic, onsite or virtually by appointment.
Please ensure ALL sections of the referral form are completed in full.
- The referral form must be signed by a doctor OR by a palliative care team member currently involved in the patient’s care
- The referrer should sign and print their name
- If the Urgency of Referral is marked as “2 working days”, the referrer must contact the Community Palliative Care Team (CPCT) by phone and speak to a CPCT nurse manager.
Please attach any available information in relation to treatment or clinical updates, including:
- CT/MRI/Other radiology reports
- Lab reports
- Hospital discharge summaries
- Hospital outpatient clinic letters
- Any other relevant information
Completed referral forms plus supporting documentation should be emailed.
Discharge from Specialist Palliative Care Services
Specialist palliative care needs can change over time. Frequently the progressive nature of the disease necessitates increasing SPC input. However, in some patients needs may decrease or stabilise such that they no longer require specialist palliative care. In the latter group it is appropriate to consider discharge with ongoing care from other health care providers. Such decisions will be made following multi-professional discussion, with the patient and family being involved in the discharge process. The patient, the referring team and all relevant health care professionals will be advised of the decision to discharge in advance. It is important to note that patients can be re-referred should they develop specialist palliative care needs once more.
A patient may be discharged from specialist palliative care if:
- There is a change in disease status such that the patient no longer has any specialist palliative care needs e.g.
- Investigations reveal less advanced disease than previously thought
- Following response to treatment
- Disease evident as only slowly progressive
- There is symptomatic improvement such that the patient no longer has SPC needs.
- Rehabilitation goals have been achieved.
- Following initial assessment, it is determined that the patient does not have SPC needs and that ongoing needs are more appropriately met by other health care agencies.
- The patient, following informed discussion, requests discharge from SPC services.
- The patient or family persistently prevent effective specialist palliative care input e.g. restricting access for assessment. The SPC team are, however, always available to offer support to involved healthcare professionals.
When a patient is discharged from the specialist palliative care service, their General Practitioner, hospital team and other professionals as appropriate are informed in writing. Patients can be re-referred at any time by their GP or hospital or Primary Care team.