Quality statement 8: Coordinated care

Quality statement

People approaching the end of life receive consistent care that is coordinated effectively across all relevant settings and services at any time of day or night, and delivered by practitioners who are aware of the person's current medical condition, care plan and preferences.

Quality measure

Measures from End of life care strategy: quality markers and measures for end of life care (Department of Health 2009).

See also quality measures and national indicators for further information.

Outcome: See the overview for overarching outcomes.

What the quality statement means for each audience

Service providers ensure that systems (such as those for information sharing) are in place, to provide consistent care at all times of day and night to people approaching the end of life, that is coordinated effectively across all relevant settings and services and delivered by practitioners who are aware of the person's current medical condition, care plan and preferences.

Health and social care professionals provide consistent care for people approaching the end of life at all times of day or night that is coordinated effectively across all relevant settings and services. They follow local policies and procedures for information sharing so that care is delivered by practitioners who are aware of the person's current medical condition, care plan and preferences.

Commissioners ensure they commission services with appropriate systems in place (including those for information sharing) to ensure that people approaching the end of life receive consistent care at all times of day and night, that is coordinated effectively across all relevant settings and services and that is delivered by practitioners who are aware of their current medical condition, care plan and preferences.

People approaching the end of life receive care whenever they need it (day or night) that is consistent, smoothly coordinated and delivered by staff who are aware of their medical condition, care plan and preferences.

Source guidance

Department of Health quality markers and measures for end of life care top ten quality markers for providers 4 and 6; and markers and measures 1.14, 1.16, 1.17, 1.18, 1.19, 1.21, 1.24, 2.2, 3.5, 3.7, 3.8, 3.13, 4.2, 4.4, 4.12, 5.2, 5.4, 5.12, 6.2, 6.4, 7.6, 8.3, 8.4, 9.2, 9.3, 9.4, 9.6 and 10.5.

NHS National End of Life Care Programme draft Spiritual support and bereavement care quality markers and measures for end of life care: spiritual support 2.

Data source

The following data sources may be relevant to the referenced measures:

Quality and Outcomes Framework (QOF) indicator RECORDS 3: The practice has a system for transferring and acting on information about patients seen by other doctors out of hours.

QOF indicator RECORDS 13: There is a system to alert the out-of-hours service or duty doctor to patients dying at home.

QOF indicator PC 2: The practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed.

The National care of the dying audit – hospitals may be relevant.

The NHS inpatient services survey asks inpatients (not specific to end of life care) questions about delayed discharge from hospital.

Office for National Statistics (ONS) National bereavement survey (VOICES) includes questions on whether services worked well together.

The draft End of life care locality register pilot programme core dataset from the Information Standards Board records details of a key worker.

Definitions

Consistent care means that the person approaching the end of life experiences seamless care that is of a uniformly high standard, regardless of which professionals are delivering the care at the time and in what setting. Also, the information that the person receives is clear and the content is neither confusing nor contradictory.

The 'source references' provide detailed examples of what information should be shared, and between which providers and services. Particular attention should be paid to communication between settings and between daytime and out-of-hours services. One mechanism for facilitating effective care coordination could be the implementation of a locality register or equivalent system. Information on the use of locality registers for end of life care is available from the End of life locality registers evaluation, supported by the Department of Health and National End of Life Care Programme. End of life care locality registers are also known as electronic palliative care coordination systems. Standardised documentation may also be helpful.

All information-sharing should be carried out with appropriate consents and in accordance with current confidentiality and data protection guidance.

Department of Health quality markers and measures for end of life care refer to a 'key worker' as an example of how coordinated care might be facilitated. A key worker is one or possibly a small number of named workers who, with the consent and agreement of the person approaching the end of life, take an important role in coordinating the individual's care. They promote continuity, ensuring the individual, and their families and carers, know who to access for information and advice. Further definition of the key worker role is available from NICE cancer service guidance recommendation 1.29.

Coordination of care is important for ensuring timely, safe and effective transfer of appropriate documentation, patient records, equipment and medication.