Abstract
Introduction: Population needs assessment for the Isle of Man predicts a 32% increase in people aged 65 years or over between 2016 and 2036. More people will be living with cancer and chronic conditions, particularly frailty and dementia, and deaths per annum are expected to increase by over 30%. Extending specialist support for this growing number of people who need palliative and end of life care prompted an innovative integrated approach to hospice and hospice influenced care. This case study describes the introduction of an enhanced community model of hospice care for the island.
Design: Temporary requirement to reduce hospice beds due to planned refurbishment was the catalyst to create and test a Hospice at Home model. From May 2019, a community coordinator provided a single point of access for patients, family/carers and professionals who require specialist hospice advice, assessment or support. The coordinator arranges assessment and follow up by an interdisciplinary team of nurse consultants, doctors, palliative care nurse specialists and social worker/ assistant. After 6pm the duty community specialist triages all calls and coordinates the appropriate community or inpatient response, liaising with out of hours health and social care teams. The integrated model provides 24/7 access to enhanced specialist palliative care in the community, responding to what matters to local people.
Highlights: Annual hospice referrals increased from 373 to 552 between 2015 and 2020. Non-cancer related referrals increased by 219%, compared to a 32% increase in cancer related referrals, and now represent 38% of hospice referrals. Monthly average community caseload doubled between 2017 and 2020 and direct hours of care at home increased from 2544 to 3839 hours. Achievement of preferred place of death for all hospice referrals increased from 29% in 2017 to 46.5% (2019 - 2020). Since refurbishment concluded in December 2020, Hospice at Home activity has been maintained with reduced demand for inpatient care. By 2021, 87% of deaths in Hospice at Home patients occurred at home with only 7% in hospice and 6% in hospital. Hospice inpatient numbers have dropped from 12 to an average of 4 with average stay of 12 days: 74% of for end of life care and 26% for symptom control. Transfers from hospital for complex end of life care increased from 30% of hospice admissions in 2017 to 56% in 2021.
Conclusion and Implications: Introducing Hospice at Home has resulted in a sustained shift towards a community based model and improved achievement of preferred place of death, a key person centred outcome. Specialist staff were supported to deliver outreach in patient’s own homes, enable hospice influenced practice within care homes and provide proactive liaison with hospital teams. The integrated community model has released hospice inpatient capacity to support complex end of life care for an increasing number of non cancer referrals. Future plans include developing specialist respite and bed-based intermediate care functions as part of the island’s strategy for integrated care. Redesign of hospice provision is an important enabler for system change and shifting the balance of care.