Community Specialist Palliative Care Team (Middlesbrough, Redcar & Cleveland)

The community specialist palliative care team influences patient care in many ways and their role encompasses clinical, consultative, education, leadership, strategic and research function.

The main aim of the team is to bring about the highest standard of care to the patient/carer by offering psychological support and expert advice on treatment options/symptom control or by indirectly acting as a resource to other professionals.

We work to four levels of intervention, which are:

  1. Providing advice, information and support to professionals without direct contact with the patient
  2. This typically involves a single consultative visit which maybe be a joint visit with the referrer, or an outpatient consultation. Our focus is providing advice so the main carer can manage the patients’ problems effectively
  3. Short-term interventions by the team relating to specific unresolved problems. Our intention is to discharge the patient from the service back to the referrer when the patients’ needs (in the relation to their problems) have been resolved.
  4. For patients who will remain under our care for a longer period or throughout the disease process. Typically, patients needing this level of intervention have multiple conditions that need specialist input, or will have been referred at a late stage of their disease.

The team will also help the primary carer in assessing and managing the needs of the patients and carers. They will not take over care but will act as a specialist resource.

Who do we work with?

  •  Patients and carers
  • GPs
  • Community Matrons
  • Community hospital nurses
  • Allied health professionals, such as dietitians, physiotherapists and occupational therapists
  • Social workers
  • Palliative support at home (Redcar and Cleveland area)
  • Out-of-hours palliative care service
  • Marie Curie
  • Macmillan information centre
  • Specialist palliative care at The  James Cook University Hospital and Teesside Hospice
  • Other specialist nurses
  • Social services
  • Learning disability services
  • Mental health services
  • Medical Staff

The team

We are a team of health professionals consisting of a palliative medicine consultant, clinical lead, Macmillan clinical nurse specialists, team co-ordinator and occupational therapists.

Where are we based?

Guisborough Primary Care Hospital Guisborough, TS14 6HZ
Tel: 01287 639100  

When are we available?

Monday to Friday 8.30am to 4.30pm excluding bank holidays.  Outside these hours please contact your GP or community nurse.  Health professionals can also get specialist palliative care adv ice from Teesside Hospice on 01642 811060.

Triage Advice

The SPCT provide a triage advice line in which a specialist nurse is available 08.30am – 4.30pm Monday to Friday (excluding Bank Holidays) to give advice and support on 01287 639100.

Face to face contact by the Macmillan SPCT Clinical Nurse Specialist (CNS) may not always be required, please ring for advice if unsure.  Telephone advice to the usual professional carer may be suffiicient to control symptoms and manage patients care.

How to refer?

The Community Specialist Palliative Care Team (CSPCT) covering Middlesbrough, Redcar and Cleveland will accept referrals for patients who are based at home, in a care home or a primary care hospital, with a life limiting illness, at any point from diagnosis. They may be experiencing difficult pain or have other complex psychological, spiritual or social needs over and above those that the usual professional carer can provide.

Pro-active referrals

Patients can be referred to the Specialist Palliative Care at certain trigger points in the patient journey – this allows the Specialist team to liaise directly with patients and feed them into appropriate arms of the service in a timely manner. It also helps to provide on-going support for patients at a time when their oncological/secondary care intervention is to cease. Trigger points include:

  • When a site-specific MDTM discussion has an outcome of ‘for best supportive care’
  • Following palliative radiotherapy for symptom management
  • When a course of palliative chemotherapy is stopped due to disease progression or patient deterioration
  • Following a diagnosis of Motor Neurone Disease

Referrals are also considered for carers of patients with palliative care needs who have complex psychological needs.

Patients are discussed by the multi-disciplinary team and undergo a Clinical Nurse Specialist led triage process by telephone to link them into the most appropriate part of the Specialist Palliative Care Service (see overleaf) or be signposted to other professionals e.g. Community Nursing Team, AHP or social care as necessary. They will also become part of an electronic flagging system within JCUH to enable early identification by hospital SPCT in event of admission.

Referrals should only be made for those:

  • Patients who consent to referral to the Macmillan Service
  • Patients who are aware of their diagnosis

Referrals should be made to the community arm of the service based at Guisborough Primary Care Hospital by completing a referral form and faxing to 01287 284023

The potential points of Community Specialist Palliative Care assessment/support offered to the patient would be:

  • Telephone support/ patient led re-referral according to need
  •  Community team domiciliary visiting service (Palliative Medicine Consultant, Macmillan Clinical Nurse Specialist, Palliative Support Sister, Occupational Therapist or Clinical Psychologist)
  • A Multidisciplinary Specialist Palliative Care Health and Wellbeing clinic session at Redcar Primary Care Hospital
  •  Referral on to existing medical outpatient clinics (symptom control clinics) based at JCUH on a Wednesday afternoon and Friday morning, or Teesside Hospice day care and outpatient facilities (and inpatient admission if severe problems identified).

Links to community hospitals

Useful documents

The process of loss and grief (1mb)
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What to do when someone dies (2mb)
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