Most people living with a life limiting disease would like to stay living in their own home, and over 70% of our care is delivered in the community. Our clinical nurse specialists work to achieve this by forming a vital link between home and the expertise of in-patient care hospice setting.
The team consists of a mix of clinical nurse specialists with the support of Palliative Care Consultants split across two sites in order to cover the Woking and Weybridge areas. They work alongside GP’s and District Nurses to ensure seamless care in the community. They visit any care setting: in the patient’s home, or a nursing or care home and accept referrals based on need rather than diagnosis; any progressive, life threatening illness. They visit patients 7 days a week and to support this the hospice provides a 24 hour advice line.
Referrals are usually received from health care professionals, and this will prompt a call from a clinical nurse specialist. The clinical nurse specialist will then provide telephone advice and usually then arrange a home visit. An initial visit would last approximately one hour, to make a full assessment of physical, spiritual and social needs. Urgent referrals are seen within 24 hours.
Future visits, ideally with this same nurse, and co-ordination of care combined with advanced care planning where possible will then be agreed. Personal care remains the responsibility of the district nursing service to coordinate.
The CNS is qualified to provide complex symptom management and psychological support in order to optimise quality of life for the patient and carers.
Further referrals will then be made to the wider team where appropriate to:
- Medical team
- Occupational Therapy
- Counselling Team
- Daycare Service
- Complementary Therapy
- Spiritual Care Team
- Social Worker