Role of Department/Service

Our multidisciplinary team provides a specialist palliative care service to people with cancer or a life threatening illness.  We cover an approximate population of 335,000 and see people in their own homes, residential or nursing homes and community hospitals.   The community involves patients across both the Plymouth PCT and some areas of the South Hams & West Devon PCT, including Tavistock, Kingsbridge, Salcombe, Chillington, Modbury, South Brent, Ivybridge and Yealmpton.

The current team is spread out between four bases within our catchment area. Our main office is based at St Lukes hospice in Plymouth. For a breakdown of our team see appendix 1

We aim to help patients and families achieve the highest possible quality of life by offering support and advice on pain and symptom management and giving emotional and psychological support to patients, their families and other healthcare professionals.

The Community Service Also Provides:

Marie Curie Nursing Service / Hospice at Home. The aim of these services is to provide palliative nursing care support to patients and their carers at home with a life threatening illness.  

This will enable the individual to die at home if this is their wish and should help to prevent an admission to hospital, nursing home or hospice.

Home Support Volunteers

There are approximately 50 home support volunteers who offer companionship and emotional and practical support to patients and families.  They do this in a variety of ways such as befriending, trips out, gardening or just going for a drive.  All the volunteers undertake a training course to prepare them for this work and also have regular supervision.

Triangle Centres

The team supports the Hospice and the Mustard Tree in running three outreach centres. These centres provide support within the community for patients who are seeking advice or information about their illness. The centres also offer complementary therapies to patients and carers.

Key Personnel	Role	Contact Details
George Lillie	Director of Community Specialist Palliative Care Services	george.lillie@stlukes-hospice.org.uk
Paula Meagor	PA to Director of Community Specialist Palliative Care Services / Admin Manager	paula.meagor@stlukes-hospice.org.uk
Carol Postle-Hacon	Team Leader	Carol.Postle-Hacon@pcs-tr.swest.nhs.uk
Martin Thomas	Team Leader	Martin.Thomas@pcs-tr.swest.nhs.uk

Activities

Team members in each base meet with a consultant from St Lukes hospice on a fortnightly basis to discuss and plan care for patients currently on their caseloads

Referral Criteria and Contact Procedures

Specialist palliative care skills can be utilised at any point along the disease pathway, particularly at diagnosis, progression of disease and the last few days of life. Specialist skills can be used in helping to manage pain and other symptoms which are difficult to control.  These skills are also used to support the patient, family and carers with psychological and emotional needs.

Referrals can be made by any member of the multi-professional team from primary care, hospital or hospice setting as well as the patient, carer or significant other.

An episode of direct care may be provided at any stage if the need for specialist palliative care has been identified.  Re-referrals can be made at any time.

Referral Procedures

The team operates a 7 day a week 9.00am - 5.00pm service.  Referrals should be made to the central office at the address below by telephone, fax or a written referral.  Referrals may also be made to a member of the team directly.

Weekend working referral criteria is illustrated in appendix 2

When a referral is made the following information is required:

Patient consent to this referral
Reason for referral
Full name, address and contact numbers
Date of Birth
Hospital number
Next of kin/main carer
Diagnosis
Treatment and medication
Social circumstances
GP and other health care professionals involved
Patient awareness of diagnosis
Main symptoms or concerns
Urgency of referral

Follow Up Including Discharge Agreement

Discharge Procedure

Patients will be discharged from our service for the following reasons:
Specialist need resolved
Patient choice

The process of discarge of patients from the caseload is outlined in appendix 3

Support for the Patient

We aim to help patients and families achieve the highest possible quality of life by offering support and advice on pain and symptom management and giving emotional and psychological support to patients, their families and other healthcare professionals.