Our community teams care for patients at the end of life who have complex healthcare needs, and who are not in hospital.
‘Complex healthcare needs’ are those which prove difficult to manage, particularly when many problems are going on at once. This could include any or all of the following:
Anyone who is registered with a General Practitioner in Ealing or Hounslow, and fits into the category of complex needs at the end of life can be referred to us. Care is based on need, not diagnosis or prognosis and we visit patients at home, in care homes and in other places of residence. Each patient is allocated to one of our Clinical Nurse Specialists. The Clinical Nurse Specialist then acts as a key worker for specialist palliative care with that patient and his or her family.
Our nursing team is supported by Allied Health Professionals. These include occupational therapists, physiotherapists, social workers and an advocacy supporter.
Other team members include senior doctors specialising in palliative medicine. These experts work alongside the rest of the team to advise patients, families and other medical professionals about the management of symptoms and complex issues at the end of life.
We also work closely with other healthcare workers such as:
If the patient’s usual Clinical Nurse Specialist is not available, other members of the team will be in a position to help. In this way, an individual patient may get to know other team members over time. Any member of the team who visits or advises a patient or family will be aware of the individual care plan and preferences for that patient and family.
Please note that routine ‘hands on’ or personal care is not provided by the Clinical Nurse Specialists. This would normally be provided by District Nursing staff and carers.
Referrals
Meadow House Hospice triages all community referrals daily.
For routine referrals, we usually phone the patient or carer within 2 working days. We agree on a time for completing the first assessment when the patient is in his or her usual place of residence.
We consider urgent referrals to be those where there is significant patient, carer or professional concern requiring immediate input. One or more of the following needs to be present for the referral to be considered urgent:
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unexpected clinical crisis – for example, rapid deterioration or imminent death
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severe uncontrolled symptoms
You can expect a call on the same working day with the aim of visiting the patient on the same day or as soon as possible.
We discharge patients if they no longer have specialist palliative care needs. We would inform the patient, the primary care team and other professionals involved in writing about withdrawing our input. We welcome re-referrals from professionals, patients or their families if the situation changes. Before we re-establish contact with a patient, we would request up-to-date clinical information from the relevant professional sources.
Download referral form
