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Effective care co-ordination

Local Care Co-ordination

Recommendation 6 : Extend the use of the current Single Assessment Process to ensure the uniform assessments processes are undertaken for people with supportive and palliative care needs.

Action

Lead

Timescale

Ensure a unified approach to assessing and documenting patients’ needs is adopted.

Adopt the national assessment tools to assess the domains of physical, psychological, social and spiritual and financial needs.

Assessment should be undertaken at key points, such as diagnosis, at commencement of, during or at the end of treatment, at relapse, and when death is approaching.

Locality Managers/ Managers of Specialist Palliative Care Team/Services.

Social Care Leads.

November 2008

Recommendation 7 : Effective inter-professional communication within and across teams, and with other service providers to meet the supportive and palliative care needs of patients and carers incorporating the principles of active case management throughout the patient journey to ensure continuity of care and support.

Action

Lead

Timescale

Develop robust relationships between community practitioners, specialist palliative care teams, and emerging model and role of community matrons.

Locality Managers Salford PCT, LA & Community Service Manager St Ann’s Hospice

April 2008

Recommendation 8 : Explicit partnership relationships should be agreed between local health and social care services and the voluntary sector, to ensure that the needs of patients with cancer and other advanced life- limiting illnesses and their carers are met in a timely fashion.

Action

Lead

Timescale

Appropriate representation and linkages of supportive and palliative care services occur to Local Strategic Partnership Board, Long Term Conditions Strategy and Local Authority.

LSG

April 2007

Recommendation 9 : Complete the roll out of the Gold Standards Framework across all GP practices in Salford and sustain its use as a model of best practice in improving community palliative care for cancer and non-malignant disease.

Action

Lead

Timescale

Complete the roll out and evaluation of the use of GSF.

Monitor and audit use of GSF.

Enable the implementation of GSF into care homes following pilot evaluation.

GSF Facilitator

GSF Facilitator. EoLC Subgroup/LIO

March 2008

March 2011

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