The Atlas of Shared Learning

Case study

Palliative care ‘day service’ re-design at Willow Wood Hospice

Leading change

The Day Services Development Lead at Willow Wood Hospice, an adult hospice providing specialist palliative care for patients with life-limiting illnesses, has transformed the day service after addressing unwarranted variation in the model of care for the patients. The service developments supported the home’s care staff to encourage empowerment and self-management in the day service patients, which led to an improvement in experience for both staff and patients as well as demonstrable improvements in well-being.

Where to look

Willow Wood recognised that their day service was modelled on a long-standing national model of care.

Embedding a rehabilitative approach to palliative care within services is an important consideration for all hospices, (Hospice UK, 2015). Not only does this approach enable people with life-limiting and terminal conditions to live as independently and fully as possible, it allows hospices to respond to increasing demand for their services in a cost-effective way.

The Day Services Development Lead also noted that improvements were needed to:

  • Support people to manage their conditions, and possibly prevent unnecessary hospital admissions and reduce length of time spent in hospital;
  • Improve functional ability through symptom management, specialist rehabilitation, emotional support and self-management;
  • Enhance quality of life for carers by including them in the holistic care model;
  • Improve their experience of care at the end of life.

Outcomes, experience and use of resources could all be tackled if the hospice addressed this unwarranted variation in service provision between the long-standing system-led model of care and a more flexible needs-led system which was attractive to a wider range of patients, engendering independence, empowerment and open and honest supportive conversations with patients and carers.

What to change

The day service at Willow Wood had operated in the same way for a long time, based on the national model established at the origins of hospice care. There was therefore an opportunity to develop the service and meet the expectations of the new evidence bases for both approaches to care and the role of specialist palliative care services for patients with wide-ranging life-limiting illnesses.

With her team, the Day Services Development Lead completed a service review and re-design, in order to address the unwarranted variation they were seeing in practice and to bring the day service model at Willow Wood up to date.

Before the change, there was also a very system-led approach to patient care in place, which gave minimal opportunity for truly active patient participation and resulted in higher levels of dependency. The local evidence also suggested that the hospice wasn’t being utilised by the patient community as much as it could. The Day Services Development Lead undertook to address this to ensure it was recognised as a care option amongst health and care staff as well as patients and their families and carers. The Lead was keen to utilise the evidence base suggesting well-being can be improved through active partnerships in care; providing peer support, self-management education, health coaching and group work.

To do things differently, and for staff to feel able to lead change, the hospice recognised that staff empowerment was a key area to address.

How to change

Supporting the Day Services Development Lead was a multi-disciplinary leadership team which included nurses, occupational therapists, physiotherapists and support workers. This leadership team held ten staff engagement focus groups to support understanding of the change. In particular these groups proposed ideas for change and made shared decisions on how the care should be provided in the future. They also looked at what could be achieved in re-designing the day service at Willow Wood to reach its potential and to address the unwarranted variation that had been identified. The sessions included discussions on culture, evidence-based approaches and guidance for best practice.

Following these focus groups and discussions, the ‘START’ clinical model was devised (Support, Therapy, Assessment, Rehabilitation and Treatment). These were key elements of care that the hospice staff felt could and should be offered. Crucially, it also provides a positive connotation for the patients as it is the start of a patient’s journey at the Hospice, one that often ends only when the patient dies.

The Day Services Development Lead, along with the hospice leadership team, then focused on the patient journey, from the point of referral to the hospice, to entering the hospice and those first, all important impressions of the culture and the environment. The key components of the START model are:

  • Open access including self-referral and rapid access from emergency care;
  • Patient-led assessment and treatment planning;
  • Supported self-management;
  • Goal setting and rehabilitation;
  • Access to the service on an individualised basis;
  • Carer support.

These components are provided through a range of modalities, such as: a neuro-clinic, working in partnership with the local neurology services, a cancer support group, a dementia café and individual, personalised treatment plans.

Adding value

Better outcomes – Reflecting increased acceptance amongst people in the local area to use the Willow Wood day services, the average age of persons using the service has changed from 64-75 to 25-64. The team use the ‘distress thermometer’ with those attending the service on initial visit and on final visits to gauge their feelings when the service. Those completed show a significant decrease in both areas of concern and overall levels of distress.

Better experience – The leadership team completed a six month evaluation, surveying staff. This showed initial positive findings, though it was still during the evolution of the model. Initial staff feedback, organisation feedback, patient feedback and activity figures are all positive. The team have collected patient stories which indicate that they feel more active in their treatment and see their relationship with day services as a “lifeline” in helping them maintain their wellbeing. Similar feedback has been received from carers. For example:

“The packages now on offer were on a much more individual basis. Willow Wood created a variety of talk groups to support both the service users and carers, overseen by a trained member of staff.  I joined a group for women with similar prognosis to myself, which to this day is still playing a huge supportive role in my journey. The discussions are always confidential and the caring nature of each lady within the group is of huge value in my life. My husband was also invited to a similar group for men who are caring for women. This has been of enormous importance in his life. It was now clearly visible that Willow Wood was reaching out to support the needs of all whose lives were being affected by cancer.”

Better use of resources – Ongoing data collection has shown a steady increase in referral rates and a significant increase in face-to-face activity. Daily attendance at day hospice before the change was 11 – 15 patients on average and this has now increased to between 20 and 30 patients using the services daily. The six month survey also highlighted that staff felt more appreciated (up from 40% to 60%) and a decrease in stress levels at work from 50% to 20% which was also linked to increased job satisfaction. The change of model freed up the potential resource within day services, both in terms of staff time and skills and the use of an environment which lends itself to active participation from patients and carers. To date (Summer 2018), nine other hospices have visited to learn about the START model and have begun to use some of the ideas. The model has been presented to a local palliative care conference.

Later in 2018, the Day Services Development Lead and team plan to undertake a further, two year evaluation to gauge impact of the service.

Challenges and lessons learnt for implementation

Willow Wood Hospice have enhanced their understanding in terms of how to deliver truly positive person-led care, how to work in partnership and advocating patient centred, individualised care and how important partnership working is in achieving these.

As with many programmes of change, it was an adjustment for staff who had worked in one way for a long time, but open, transparent communication has empowered all staff to engage in the change.

Willow Wood continues to widen their impact by developing a mobile community hub, which takes the service to the patients rather than them initially coming to the Hospice.

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