Care at home

The community team is made up of nurses, doctors, occupational therapists, physiotherapists, a pharmacist, social workers and a benefits adviser, who each have specialist training and experience in caring for patients with a life-limiting illness.

• Symptom control – we work with GPs and other healthcare staff to advise on medication and other help to improve difficult symptoms which are troublesome for patients.
• Support for the individual and the people who are most important to them – this may mean referral to other organisations that can help.
• Advice about benefits and other sources of financial support.
• Support with planning for the future.

After a routine referral is made, patients are sent a letter explaining the service. The nursing team will then make contact to arrange an initial assessment, either in outpatients, at home or via video link.

When an urgent referral is made, or if there is a concern about symptoms recorded on the routine referral form, a nurse will make a brief phone call to the patient or their advocate (person who is caring for or supporting them), to explore this further and provide initial advice if required. A more complete initial assessment will then be arranged at a later date, depending on need.

At the end of the initial assessment, a care plan will be created with the person and the people important to them. This can be reviewed at a later stage. With the person’s consent, we will share this with other healthcare professionals.

It is important to us to treat people as individuals and enable them to live as well as possible in the time they have left.

The patient’s GP is responsible for care at home, requesting our palliative care advice when needed but remaining the key healthcare professional responsible for prescribing medication in the community.

The palliative care team work alongside other hospital teams, who remain responsible for any treatment that they advise. Some patients also have a Specialist Nurse linked to their condition who can offer support.

For more information, please visit the Oxford University Hospitals palliative care hub.