The third step is about co-ordinating services. Once a care plan has been agreed it is important that all the services required are effectively co-ordinated. A lack of co-ordination can mean a

resident’s needs and preferences are not met.

Time: Half day

Aim: A system is in place to ensure co-ordination of care takes place

Objectives:

By the end of the session the Care Home Representative will be able to:

• Recognise the importance of sharing information with the wider multidisciplinary team

• Define the role of a Key Worker

• Identify the appropriate time to request anticipatory prescribing of End of Life Care medication and equipment

• Develop further the Care Home End of Life Care Policy.

Supporting Documents:                                                            

Attendance register  

This basic register can be used at any events and workshops to keep a record of delegates.

The Routes to Success

The programme is based on the Routes to Success and this document can provide further background to the programme. 

Support sheet 1 

This support sheet provides a template for a Directory of Key Contacts.

End of Life Checklist  

This tool uses the North West End of Life Care Model to provide a checklist of actions which can be carried out at each stage of End of Life Care. Further action can be added to meet local requirements.  

Support sheet 10 

This support sheet provides a flowchart for supportive care.

Support sheet 14 

This support sheet provides information on using the NHS continuing health care fast track pathway tool.

Key worker policy 

These guidelines specify the role of the ‘key worker’ and apply to the delivery of both supportive and palliative care, and therefore cover the needs of patients requiring end of life care.

Role of the key worker 

This is a desciption of the role of the key worker for end of life care.

Key worker poster  

This poster illustrates the role of the key worker and can be displayed within the care home as an aide memoire 

North West End of Life Care Register 

This useful tool can be used to register and track individuals who may require end of life care.  (Copy without example)

Step 3 case study 

This learning aid provides a case study which can be used alongside the work plan for Step 3.

Step 3 to do list  

This provides a checklist of actions which should be completed before the next workshop.

Evaluation form  

This evaulation form can be used to allow delegates to provide any feedback.  This feedback will help facilitators to continually develop and improve the delivery of the programme. 

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