Disclaimer
This process was developed for Penrose Health, and is based on NICE guidelines from June 2023 You must have the appropriate training, use your clinical judgement, and escalate when necessary.
Why we do this review
To record the number of patients requiring palliative care, and support them through their care.
Summary
Palliative care is the care of patients living with terminal or chronic illnesses. This type of care aims to make patients feel supported and comfortable by:
- managing symptoms
- offering emotional or psychological support
- offering practical support (e.g., equipment or manual care)
End of life care is a form of palliative care. Patients can receive palliative care at any point after their diagnosis, including whilst they’re still receiving treatment.
Read about the relevant QOF indicators from NHSE here
Care pathway
Part of QOF and Premium Spec requirements
This pathway is designed to record the number of patients requiring palliative care, and support them through their care.
1️⃣ Booking the appointment
Care Coordinator (remote)
- Review palliative care register monthly for patients:
- who have not had a review in the last six months
- whose GSF stage has changed recently or warrants more frequent reviews (i.e., if in green, yellow or red category)
Gold Standard Framework (GSF)
Red | Daily deterioration |
Blue | Prognosis > 12 months |
Green | Monthly deterioration |
Yellow | Weekly change |
- Call the patient to book an appointment (F2F or telephone) with a care coordinator.
Please note that a home visit may be required for some palliative care patients. See our Home Visits page for more information.
Always check if the patient requires an interpreter (book double appointment if they do), if there’s anything else pending in the pink QOF box that we can address while we’re speaking with the patient, and that their contact details are correct
2️⃣ Carry out review
Care Coordinator (F2F or remote)
- Open the clinical template ‘Future Planning (inc PCSP) (v17.7) (Ardens)’ on EMIS. Complete pg. 2-3, with the exception of the cardiopulmonary resuscitation section.
- Complete a Personalised Care & Support Plan (PCSP), if appropriate
- Assess patient need and provide appropriate referrals and advice as below
- For OT, refer by borough as per our Occupational Therapy page
- For district nurse, refer to District Nurse (Lewisham) or District Nurse (Southwark & Lambeth)
- If GP intervention is needed OR if the patient has not seen their named GP in the last year, book a follow-up appointment.
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3️⃣ Follow-up appointment
Named GP (F2F or remote)
- Open and complete the remaining sections of the ‘Future Planning (inc PCSP) (v17.7) (Ardens)’ clinical template.
- Ensure patient has an updated urgent care plan. If they do not, create one and upload to Valida via EMIS.
- If further input is needed, consider referral to Specialist Palliative Care
For guidance on the cardiopulmonary resuscitation section, visit our ADRT & DNACPR page.
For information on how to install and access Valida, click here.
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Prevalence
For what to do when a patient dies, please see our Reporting Patient Deaths page.