Supporting homeless people with collaborative palliative and end of life care

Introduction

In 2013, a small multiprofessional team of healthcare assistants, advanced nurse practitioners and occupational therapists at Sussex Community NHS Foundation Trust set up and supported the commissioning of The Homeless Project, a scheme to provide community outreach to patients vulnerably housed and homeless in the Brighton and Hove area. The team provides support for patients in hostels, emergency and temporary accommodation, as well as those who are rough sleeping and, additionally, works in partnership with Martlets Hospice for patients receiving palliative or end-of-life care. Since 2016, the team has developed to include, not only nursing, but also occupational therapy and physiotherapy professionals.

Project aims

In January 2021, we set up a project to create and deliver a palliative care education and support programme to >150 non-clinical staff working in supported, temporary and emergency accommodation, including 16 supported hostels and two day centres, and other care providers, such as those supporting rough sleepers in Brighton and Hove.

Before we started, we had a clear aim to support and break down barriers so homeless and vulnerably housed patients could die with dignity and respect in their preferred place of care. We also sought to:

• Allow for quicker identification and support for patients with deteriorating health needs who may or may not be palliative;
• Provide earlier clinical interventions, if possible, to help support patients to stabilise their health;
• Empower non-clinical frontline staff to have discussions with their clients around their advanced ill health and their wishes in context to this;
• Educate staff to recognise signs and symptoms of deteriorating health.

Implementation

Many frontline staff working with our patient group are non-clinical and had a lack of understanding and fear around supporting patients through an “expected” death – namely, when the individual is diagnosed with a terminal illness or condition which, based on current medical knowledge, is not expected to improve but is likely to deteriorate. By working with Helen Lyons from Martlets Hospice, who had secured funding through Hospice UK, we developed an education programme for frontline staff to improve their knowledge of deteriorating patients, and palliative and end-of-life care.

Educating frontline staff would:

• Accelerate signposting for appropriate support from relevant services;
• Reduce fear around caring for such patients by increasing understanding of what to expect and what services were available to the patient.

Challenges

Our main challenge was adapting our teaching to be available on Microsoft Teams and Zoom, as the Covid-19 pandemic hit. The other challenge was ensuring we could reach as many frontline staff as possible. Our supported accommodations operated on different shift patterns, so we had to run at least two or three sessions for 12 months per hostel to cover all staff interested in attending the training. Over six months, we developed a webinar to help those who were unable to attend.

“The judges were inspired by the collaborative working, passion and commitment of care delivery to marginalised groups that offered choice, dignity and respect for people requiring palliative and end of life care in homeless health” (Judges’ comments)

Outcomes

This service saw an increase in the number of patients dying with dignity and respect in their preferred place of care with the right support. To date, three patients died in their preferred place of care; at time of writing, we had four palliative care patients being supported in emergency and temporary accommodation, hostels (supported accommodation) and nursing homes.

Frontline staff reported that the education they received empowered them to have conversations with their clients about palliative and end-of-life care. Many of the staff are with their clients at medical appointments when a palliative diagnosis is given; they said the training helped them support their clients with discussions about their diagnosis. This has been noted in an increase in referrals of patients being identified as having deteriorating health needs.

A meeting on deteriorating patients involving the hospice and Homeless Health Inclusion Team (HHIT) was trialed with two supported accommodation units to identify patients sooner and ascertain how to collaboratively work towards supporting the patients. The HHIT and Martlets will continue to break down boundaries in how patients access high quality palliative and end-of-life care in their preferred place of care by educating both clinical and non-clinical staff.

Frontline staff have felt empowered to have conversations with their clients around their palliative diagnosis and how they would like to be supported to continue their life. By understanding the support on offer, agencies have felt empowered to support their clients/patients in identifying their preferred place of care and support them to die with dignity and respect. It has also allowed for earlier identification of deteriorating patients by frontline staff who, thanks to the education programme, are more likely to recognise the signs and symptoms, which could allow patients access to clinical care more quickly. This has, at times:

• Prevented further patient deterioration;
• Allowed patients to be treated and stabilised;
• Allowed some patients to be helped to hospital, where necessary, or to have the right diagnostics and investigations around palliative care and at end of life.

Nurse-led initiative

Our initiative was completely nurse-led: Caterina Speight has expert knowledge in providing nursing care for homeless and vulnerably housed patients and Helen Lyons, as a senior nurse in palliative care at Martlets, is passionate about supporting patients who are marginalised to have equal access to palliative and end-of-life care.

Helen secured funding to develop the project and support the training package, auditing and structure. Every Wednesday was spent preparing and delivering the education to services and, through close working, feedback was evaluated and the training continually adapted.

Conclusion and future plans

To our knowledge, this is the first kind of training on such a scale to be delivered by two different healthcare providers, working collaboratively for the better good of patients. It provided an amazing opportunity for both agencies to learn from each other by delivering education and understanding what challenges each agency faced in the context of deteriorating patients and palliative and end-of-life care.

Both teams were passionate about empowering frontline staff through education to feel confident that they could provide support to their clients with deteriorating health, palliative care and end-of -life care needs. Through their increased understanding of these areas, frontline workers could then, not only help signpost, but also engage patients with the right services to support their advanced healthcare needs.

Patients also increased their understanding of how our teams help patients and their carers to use advance care plans to support their wishes and options around preferred places of care, including dying at their supported accommodation with the right assistance in place.

We are in discussions with Hospice UK on how this could be adopted nationally in other areas or hospices, and presented at their conference in November 2022. Locally, Lisa O’Hara, a nurse consultant in end-of -life care at the trust, is in discussions with the new integrated care board on how this education can be delivered and utilised throughout Sussex.

A working group has been established to ensure this training is embedded and ongoing for all future staff working in Brighton and Hove. Continued collaborative working with Martlets will also help develop policies and procedures for the safe storage of controlled drugs for palliative care and the commissioning of night sitters or end-of-life doulas.