GMCSU on Behalf of NHS HMR CCG - Integrated Palliative Care & End of Life Care Service.

Descriptions

GMCSU on behalf of NHS HMR ClinicalCommissioning Group is inviting potential bidders through this tender exercise the oppertunity to deliver a safe, cost- effective End of Life & Specialist Palliative Care service which must be operational from the 1.4.2014.The aim of the service is for a clinical consultant or clinical specialist led, multi-disciplinary team to work collaboratively with primary care clinicians and other services involved with patients to enable those with specialist palliative care and end of life care needs to maintain their identity and independence, whilst also supporting their family, friends and carers during the changing phases of their illness. The focus of the service will be to improve the quality of care for patients at the end of their life.The service will adopt a multi-disciplinary approach across internal and external services to ensure that services provide complex symptom management and holistic care with the aim of ensuring that patients have the optimum quality of life until death.It will achieve this by working collaboratively across primary and secondary care to facilitate choice in respect to preferred priorities for care and death and thereby contributes towards reducing avoidable hospital admissions and reducing length of stay. The service will educate and empower individuals and their families so they can make informed choices about treatments, management of care, End of Life Care including all palliative current /future care needs.The integrated palliative and end of life care service described in this specification will include specialist palliative care nursing, hospice at home care, night sitting services (currently jointly funded by both the CCG and RMBC) and intermediate and general end of life care. The service will also incorporate education, training, support and advice for non-specialist palliative care providers including GPs, nursing/care homes within HMR and other providers within the Borough.The service will be managed by one single provider or a coalition of providers with one lead provider acting as a prime contractor on behalf of the coalition.The objectives of the service are as follows:— To create an integrated, high quality, patient centred and co-ordinated community palliative and end of life care service within the conurbation of HMR CCG;— deliver a single point of access for community palliative and end of life care services, to be accessed by patients, their carers and families, GPs and service providers within the Borough;— provide clinical triage and assessment of patient and carer needs;— deliver effective individualised advance care planning for patients approaching the end of life;— enable people to be treated and die in their preferred place of care;— reduce A&E attendance and unnecessary hospital admissions for patients approaching the end of life.— provide support, advice, training and education for GPs and health and social care providers within HMR Borough.— ensure effective communication with all partners and agencies involved in the care of patients, most significantly the patient, their carer and family;— increase the number of patients dying in their preferred place of care;— increase the number of advanced care plans within the Borough;— support patients, carers and their families holistically and individually throughout their contact with the service and into bereavement if required;— undertake the role of care coordination when the service is the best placed to do so, including liaising with providers and funders of other care e.g. continuing health care;— support and facilitate within Multi-disciplinary team meetings where appropriate;— support in the identification of patients approaching the end of life and to provide support to patients, carers and families and other health and social care providers when required;— delivery of 24 hour, 7 day a week telephone advice line, accessible to patients, carers and families and health and social care providers;— facilitate and support rapid discharge from hospital where required; and— Actively engage and encourage hard to reach groups and provide effective ethnically sensitive care.Strong clinical leadership will be required to develop the vision for the service and promote its future development, with a strong emphasis on new ways of working, collaboration and innovation. Communication between community, secondary care clinicians, general practitioners, patients and their carers will be essential to the new integrated service.