Special Palliative Care Team

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Introducing our specialist palliative care teams

The team of specialists involved with Countess Mountbatten House includes consultants in palliative medicine and doctors with other specialist skills, along with clinical nurse specialists, occupational therapists, physiotherapists, social workers and a multi-faith and belief chaplaincy team.

The service, which also offers expert psychological and emotional support to patients who may be dealing with fears and anxieties related to illness and treatment, and their families, works in partnership with care from general practitioners (GPs) and the community nursing service.

This multi-disciplinary approach brings together a range of experts who work together to ensure you receive care that best meets your needs. Each team is introduced in more detail, please see page nine.

Meet the specialist teams

The hospital palliative care team (HPCT)
Our hospital team is part of the University Hospital Southampton (UHS) specialist palliative care service based at Southampton General Hospital.
The team is able to make specialist recommendations to complement existing services. These may focus on the management of pain and other symptoms related to your illness, as well as a range of other issues, for example; leaving hospital, complex clinical decision making and your future care preferences.

Our core team comprises consultants, nurse specialists, a specialist registrar on rotation and administrative staff. We also link closely with the end of life care team.

The HPCT accepts referrals for patients over 16 years of age with any advanced illness who are inpatients on any ward at Southampton General or Princess Anne Hospital, including the emergency department and the various intensive care units. If you are being supported by the HPCT, you will also remain under the care of your existing consultant/s.

The team provides cover between 8.30am and 4.30pm, seven days a week.

At weekends and on bank holidays, a nurse provides onsite assessments and reviews with telephone advice available to them from the on-call palliative medicine consultant.

Contact the hospital palliative care team

Our telephone number is: 023 8120 4126

The community specialist palliative care team (CPCT)

Our community team, led by a specialist in palliative medicine working alongside clinical nurse specialists (CNS), offers expert support and advice to patients at home or in residential care and their families. This includes symptom management, medication and pain-relief, as well as psychological support. The frequency of visits will depend on your personal requirements, and will be reviewed regularly by the clinical nurse specialist.

We work alongside GP surgeries and community healthcare teams, and as a community patient you will remain under the care of your GP who will usually be responsible for your prescriptions and any changes in medication required.
If appropriate for your needs, a referral to the CPCT can be made by either your GP or a member of your hospital healthcare team. New patients are offered a home visit or outpatient appointment from either the doctor or CNS, depending on the individual circumstances. The team does not provide ‘hands on’ personal care, but we can liaise with primary care teams to arrange this if needed.

Symptoms will be reviewed by the doctor or another member of the team if necessary. Admission to the inpatient unit at Countess Mountbatten House can be arranged if symptoms cannot be controlled at home. Admission to the ward is also possible for care whilst dying, if this is the individual’s preferred place of care and depending on availability of beds in the unit.

Contact the CPCT team
You will be given the contact details of your clinical nurse specialist (CNS).
Please leave any non-urgent messages on your CNS’s answer phone. This will be checked regularly between 8.30am and 4pm, Monday to Friday.

If your call is more urgent
Please ring reception on: 023 8047 7414 and ask the team to contact the CNS via their mobile phone (Monday to Friday). If you need urgent advice outside of normal working hours, please contact your GP surgery or out-of-hours service, or the inpatient unit on: 023 8047 5528.
A clinical nurse specialist is also available to give specialist advice to healthcare professionals at weekends and bank holidays.

The therapy team
Our palliative care therapy team consists of occupational therapists, physiotherapists and a therapy technician. You may be seen by the therapy team at the inpatient unit, the Hazel Centre, as an outpatient, or in your own home.
Therapy is an integral part of palliative care, and the team aim to enable you to retain the greatest possible level of independence and a sense of control, in all areas of your life. The views and wishes of patients and their families are an important part of therapeutic assessment. We work closely with you and your family to consider what is important to you, and agree your treatment plan together.

The therapy team can help you with the following:
• day to day tasks, mobility and transfers
• self-management strategies for anxiety or fatigue
• equipment assessment
• breathing problems
• relaxation
• specialist seating and wheelchair assessment
• rehabilitation including tailored exercise programmes
• moving and handling advice

Accessing the palliative care therapy team services
If you believe you require an assessment by the therapy team, speak to one of the professionals involved in your care, who can refer you if appropriate.
Once you have been referred the therapy team will carry out a full assessment with you, either at home or at Countess Mountbatten House, depending on your individual requirements.

The social work team
Our team of qualified social workers have knowledge and experience in palliative care. We can provide emotional and practical support to you and your family and carers, whether you’re an inpatient, attending day care or based in the community. The social work team leads on discharge-planning from the ward and can provide all the information and help needed to put
in place care at home, and can also support you to find a residential/nursing home placement if applicable.
The team can also offer advice and information on the following:
• support for carers
• financial advice
• emotional support
• bereavement support and signposting to services
• liaising with the local authority and other professionals
• advocacy (helping your voice and opinions to be heard)
• wellbeing tools
• resources for children and teenagers

Contact the social work team
Our telephone number is: 023 8047 5531

The care home education team
Our education team works in partnership with health and social care organisations within the Countess Mountbatten House catchment area, providing support and education to nursing and residential homes in the region and enabling delivery of high quality end of life care provision. Courses delivered by the team of expert clinical nurse specialists include an end of life care quality
improvement programme and a programme for residents with advanced dementia, known as Namaste care.

We also run a care home palliative care champions group which meets regularly to provide ongoing support, updates and education for care home representatives.

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