Rehabilitative palliative care in practice

Examples of innovation and good practice in rehabilitative palliative care.

Multidisciplinary First Contact Assessment Team

The St Joseph’s Hospice’s First Contact Team (FCT) is a multidisciplinary model of triage and assessment, developed in 2012 in response to a need to improve patient and carer access to all the services of St Joseph’s Hospice. We recognised a need to improve the quality of our services, to improve the response times for patients, their families and carers who were referred, and to ensure all those referred were appropriately signposted to the whole range of services provided by the hospice.

From the outset, the model has pioneered holistic assessment through the introduction of a multidisciplinary approach to triage, utilising the skills of health and social care professionals across the hospice team.

How does the model work in practice?

Following comprehensive telephone triage by a team of trained administrators and clinical nurse specialists, new referrals to the hospice are discussed at a daily multidisciplinary morning meeting. Here the professional or professionals best suited to undertake the First Contact assessment of the patient’s (and/or carers’) needs is identified and agreed. This may be undertaken independently or as a joint assessment, either in the community or outpatient settings.

How does this model best support patients’ needs and priorities?

  • Patients have access to the multidisciplinary team skills and knowledge best suited to assess their needs. For example, patients whose presenting issues relate to compromised mobility and function, breathlessness, fatigue or lymphoedema are first assessed by a physiotherapist. Physiotherapists bring specialist skills in physical assessment including the ability to undertake comprehensive assessment of respiratory and neurological systems, alongside function. This represents a significant benefit for patients, eg whose history suggests a risk of malignant spinal cord compression or acute exacerbation of COPD, and can reduce the need for multiple professional assessments.
  • Utilising the skills of the multidisciplinary team in planning care from the start of the hospice journey, patients and their families can now hope to receive all the appropriate services that the hospice offers in a proactive, timely way.
  • Patients can be supported at an earlier stage in their illness by accessing appropriate multidisciplinary team services relevant to their needs and preferences. Rehabilitation can be a positive gateway into hospice services, helping to engage patients earlier or when they may be reluctant to use hospice services due to well-recognised stigma and fear.
  • Patients are supported by a lead professional in the multidisciplinary team which corresponds to their needs. For example, if a patient is stable and their predominant input is from the physiotherapy service, then the physiotherapist may take this lead role. The lead professional maintains strong communication with the wider multidisciplinary team to ensure robust governance and safe, timely transfer of care to involve other services when a patient’s needs change.
Nigel Dodds, Nurse Consultant – Community Palliative Care, St Joseph’s Hospice


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