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Table 1 The organisation of care across the PHCT

From: Primary palliative care team perspectives on coordinating and managing people with advanced cancer in the community: a qualitative study

PHCT member Role with patients with palliative care needs Timing and type of involvement How is involvement initiated Method of involvement
GP Provide general palliative care
Assess patients’ needs
Prescribe and manage medications
Identify patients approaching end-of-life
Care planning and anticipatory prescribing
Manage and coordinate end-of-life care
Prior to diagnosis
Continuous however during period where patient is receiving treatment may be intermittent until later stages
Patient presents to GP
Referral from oncology
Appointments in surgery
Home visits
Occasional phone calls to patient and family
District nurse Provide general palliative care alongside GP, i.e.: management, coordination, and orchestration of services to enable good home care for dying patients
Physical nursing needs, i.e.: wound management, continence care, catheter care, medication and syringe drivers
Last few weeks/days of life
Often receive a referral soon after diagnosis of advanced cancer so will have initial meeting and then intermittent contact until later stages
Continuous involvement in last few weeks/days of life
Referral from GP, oncologist, community matron, joint care manager, clinical nurse specialist Always home visits
Sometimes phone calls to patient and family
Clinical nurse specialist Provide specialist psychological and physical symptom management that Can be from diagnosis of advanced cancer
Intermittent
Referral from GP, district nurse, oncologist
Complex needs that cannot be managed by the GP and district nurse
Always home visits
Often phone calls to patient and family
Community matron Provide care and support to people with long-term chronic conditions to keep patients as healthy as possible and living independently
Only involved if patient has a long-term chronic condition and cancer
From diagnosis of chronic condition
Continuous
Referral from GP, district nurse, hospital team Always home visits
Sometimes phone calls to patient and family
Joint care manager Provide a service to adults aged 65 years and over with complex health and social care needs and adults of all ages who have been identified as eligible for NHS Continuing Healthcare funding
Assess health and social care needs; plan, coordinate, and review services required
Discharge from hospital
At home but at risk of being admitted to hospital/care home when don’t need to be
In a Community Intermediate Care bed or at home with services to help you with personal care from Leeds Community Healthcare NHS Trust and need ongoing care
Continuous
Referral from any health or social care professional Home visits
Complex and palliative continuing care service Provide bespoke packages of care to fast-track patients with highly complex continuing care needs Last few days of life
Continuous
Referral from district nurse Home visits