Case study:

11 May 2010

Community Supportive Care Pathway in Solihull NHS Care Trust

Key points

Solihull NHS Care Trust has developed a multi-professional care pathway to support patients with end of life care needs in the community.

The Community Supportive Care Pathway was successfully piloted across 60% of the community nursing teams in 2006/07. It is now planned to extend this to all integrated community teams by the end of February 2009.

The audit of the pilot stage showed a number of improvements in patient care. The new care pathway templates made it much clearer when a patient had supportive and palliative care needs, and then when they had comfort care needs in the dying phase. Recording of preferred place of care improved as did prescribing anticipatory medicine for the dying phase.

In addition there was better recording of advance care planning discussions, of patient outcomes in relation to symptom control and date and place of death.

The pathway templates, which are divided into two parts, one for Supportive and Palliative Care and the other for Comfort Care in the Dying Phase, were developed by a small working group consisting of community nurses, other specialist nurses and a social worker. Parallel to this a pathway working group of GPs was also established to support the medical assessment component of the pathway.

The templates can be used within the community nursing care plan folder, complementing existing assessments and care planning documentation. Guidance notes have also been developed for each community nursing team on use of the pilot documentation.

The pilot follow-up audit highlighted the need to amend some of the documentation to prevent repetition of information and improve completion of assessments. For instance, there was some confusion over where to record date of visit on the supportive and palliative care plan and the Problems And Concerns Assessment (PACA) symptom control assessment tool and over where to record the pain assessment score on the PACA pain assessment tool. The pilot also identified the need to develop Advance Care Planning and recording of patients’ wishes.

Only 11% of patients in the pilot study were identified as having a non-cancer diagnosis. And none of the care plans had a recorded Do Not Attempt Resuscitation (DNAR) for patients in the dying phase. The trust has developed the DNAR policy since then as well as a template for recording DNAR decisions.

There will be an annual trust audit of the pathway, reviewing patient outcomes and variance monitoring. The pathway has also been linked to the trust’s electronic clinical system so that activity across community services can be monitored in relation to the pathway codes.