DOMAIN 7: COLLABORATION AND CO-ORDINATION (CCo) Action Subject Proposed action Timescale Lead Indicators of success CCo1 Sharing of Utilise immediate discharge letters (with ACP information June 2014 Ian Marshall Immediate information and request to update KIS/NHS24) to ensure that awareness discharge letters of preferences and values of patients/families are shared are in use properly between the various teams and agencies CCo2 Gold Standards Support GP practices to review the membership, frequency March 2015 Jill McKane GSF meetings meetings and focus of their Gold Standards Framework meetings to Ruth Ward ensure that they are multi-professional, include patients with non-cancer palliative care needs and meet regularly. CCo3 Integrated Hold a facilitated workshop to examine ways of Complete Jackie Chaplin Workshop has community a more integrated approach to palliative care taken place and services patients in the community. report has been disseminated CCo4 Integrated Investigate the possibility of developing an integrated March 2015 Thelma Bench Meetings have community community team that adopts a proactive approach to Joyce Allan taken place services meeting the needs of patients with life-limiting conditions in Anne Mills between all parties the community. Sandra McConnell CCo5 Integrated Monitor and support moves to create a Transformation March 2015 Anne Mills Proposal is agreed community Champion post or similar. Beth Culshaw upon services Thelma Bench CCo6 Integrated Monitor the on-going review of the home and out-patient December 2015 Thelma Bench Quarterly feedback community services at Ardgowan Hospice and support plans to achieve Joyce Allan to Palliative PIG. services greater integration with primary care services. Anne Mills Sandra McConnell CCo7 Integrated Support improved links between (and understanding of) September 2014 Christine Hennan Development community services (e.g. Home Care and hospice community CNS team). Anna Forde Group set up. services Joyce Allan Hospice and Gerontology nurses attending CCo8 Information Support efforts to resolve any issues with ePCS and KIS to June 2015 Beth Culshaw All relevant settings quality, enable them to be used optimally and accessed by all Thelma Bench report having
DOMAIN 7: COLLABORATION AND CO-ORDINATION (CCo) Action Subject Proposed action Timescale Lead Indicators of success CCo1 Sharing of information Utilise immediate discharge letters (with ACP information and request to update KIS/NHS24) to ensure that awareness of preferences and values of patients/families are shared properly between the various teams and agencies June 2014 Ian Marshall Immediate discharge letters are in use CCo2 Gold Standards meetings Support GP practices to review the membership, frequency and focus of their Gold Standards Framework meetings to ensure that they are multi-professional, include patients with non-cancer palliative care needs and meet regularly. March 2015 Jill McKane Ruth Ward GSF meetings CCo3 Integrated community services Hold a facilitated workshop to examine ways of a more integrated approach to palliative care patients in the community. Complete Jackie Chaplin Workshop has taken place and report has been disseminated CCo4 Integrated community services Investigate the possibility of developing an integrated community team that adopts a proactive approach to meeting the needs of patients with life-limiting conditions in the community. March 2015 Thelma Bench Joyce Allan Anne Mills Sandra McConnell Meetings have taken place between all parties CCo5 Integrated community services Monitor and support moves to create a Transformation Champion post or similar. March 2015 Anne Mills Beth Culshaw Thelma Bench Proposal is agreed upon CCo6 Integrated community services Monitor the on-going review of the home and out-patient services at Ardgowan Hospice and support plans to achieve greater integration with primary care services. December 2015 Thelma Bench Joyce Allan Anne Mills Sandra McConnell Quarterly feedback to Palliative PIG. CCo7 Integrated community services Support improved links between (and understanding of) services (e.g. Home Care and hospice community CNS team). September 2014 Christine Hennan Anna Forde Joyce Allan Development Group set up. Hospice and Gerontology nurses attending CCo8 Information quality, Support efforts to resolve any issues with ePCS and KIS to enable them to be used optimally and accessed by all June 2015 Beth Culshaw Thelma Bench All relevant settings report having
Phase-3-Action-Plan-Final-280514-REPRINT.docx