Maxine Leggett and Kim Wilding
Macmillan Clinical Nurse Specialist and Out of Hours Co-ordinator
West Lincolnshire PCT
Tel: 01522 512999 and 01522 548203
Email: maxine.leggett@westlincs-pct.nhs.uk; kim.wilding@westlincs-pct.nhs.uk
Summary:
The aim of the scheme is to fast track access to appropriate medical and nursing care for terminally ill patients.
The objectives are to prevent computer triage and to provide immediate contact, at any time of the day or night, with a clinician providing reassurance, support and home assessment as required. A further objective is to reassure professionals that care will continue out of hours.
The outcome of the scheme, besides providing the care to the patient, is to highlight to all Out of Hours staff that the patient has palliative care needs and requires immediate assessment and care.
Abstract:
To provide a system where patients can have fast track access to Out of Hours services and have direct contact with an experienced clinician and this is achieved by the provision of the “Green Card” scheme.
Front line staff identify patients with palliative care needs through the mechanism of the Macmillan Gold Standards Framework. These patients are given a small green coloured card with the direct contact details of the Out of Hours service and an explanatory leaflet. This enables patients and their carers to have a direct telephone conversation with an experienced clinician and they are assured that this can be at any time of the day or night. This often results in a home assessment.
During the home assessment the patient is given the choice of where they want to receive care, whether it be at home or in hospital, or in a specialist palliative care bed.
Inappropriate hospital admissions are avoided because the patient is (a) bypassing computer triage (b) connecting with the appropriate clinician and (c) receiving rapid response to their individual and special need.
The project is underpinned by the Gold Standards Framework, the Departmental standards for Out of Hours services, NICE Guidance for Supportive and Palliative Care and the NHS Cancer Plan.
The scheme was promoted with clinicians who provide direct patient care in the community and received very strong support locally by the PCT, the PCT Head of Nursing Services, the PCT Macmillan GP and the Countywide Palliative Care Lead. It was self evident, that although the scheme was simple in concept, it was very effective.
An audit was undertaken with District/Community Nurses to evaluate the scheme and make any appropriate changes. The scheme required relatively few “tweaks” but the developers of the scheme listened to the comments made by patients through their district nurses and adjusted the system to make it more patient centred.
An example of this is ensuring that the Out of Hours services have specific details on the patients' care needs.
At the development stage it was found that the Out of Hours staff had educational needs within the palliative care field. Local training was developed to ensure these needs were met. As a by-product, this has raised the profile of palliative care within the community and reinforced the importance of seamless working.The scheme has been operational for 18 months in West Lincolnshire PCT. An audit was undertaken and demonstrated a high level of patient satisfaction. Statistical information has demonstrated that once the patient has used the service they continue to use the service with increasing frequency until the end of life. The NHS complaints procedure is used to monitor the Out of Hours service and West Lincolnshire PCT has not received any palliative care patients’ complaints for the Out of Hours period. We believe this is a unique position.
The audit identified a number of positive outcomes within the patient’s experience. These included “excellent”, “reassuring”, “very good idea”, “works well”, “quick response”. Verbal responses directly from patients and their carers include “removed stress”, “easy to use”, “very reassuring”. Patients and carers feel they are getting a ‘special service’ and realise that this service could be a very valuable part of their care pathway. Relief at being able to contact someone ‘anytime’ is noted very favourably.
With the addition of a Community Pharmacy Scheme for 24/7 access to palliative care drugs there have been “nil” untoward incidents in the PCT in the Out of Hours service since April 2005.
The Out of Hours service is an emergency response service, having responsibility for all areas of health care, besides caring for patients with palliative care needs. The Green Card Scheme has supported the Out of Hours staff to engage fully with “in-hours” staff in respect of patients with palliative care needs. This has encouraged communication between the two arms of the service and promoted seamless care for the patient.
The Green Card can be adapted to meet the needs of ethnic and minority groups.
The Gold Standards Framework is well developed in West Lincolnshire PCT and the Green Card Scheme works in conjunction with this important initiative. The Lincolnshire-wide Palliative Care Group has supported the use of the card and the Palliative Care Lead has promoted the card at national conferences. The Green Card Scheme was submitted to Mid Trent Cancer Network “Good Ideas” initiative where it received positive feedback. Lincolnshire is in the process of developing a countywide strategic palliative care pathway and providing the card to patients will be a key component within the provision of Out of Hours care.
The Green Card supports the initiatives being undertaken within the Marie Curie Delivering Choice programme within Lincolnshire which aims to ensure that palliative care patients have choice in their place of care.
Two nurses developed the Green Card Scheme, one from the Out of Hours service and the other a Macmillan Nurse. They realised there was a gap in the service where patients with palliative care needs were unable to have an instant direct telephone contact with a clinician, particularly out of hours. This is often a frightening time for patients and when they are most vulnerable. The Out of Hours triage programme frequently pointed the patient to the 999 ambulance service, often resulting in an inappropriate hospital admission causing undue stress for the patients and their carers.
The Green Card system has significantly reduced the need for patients and their carers to phone 999. It is an inexpensive, easy to use system which enables patients most at need to have a service which allows direct access to an experienced clinician at any time. The use of the cards is monitored and only given out to patients by District and Macmillan nurses to those patients who really need them and therefore not diluting their effectiveness.
