To ask the Minister of Health (i) to detail any mandatory referral pathways that are triggered when a patient is discharged from hospital with a palliative diagnosis; (ii) whether these pathways automatically notify community nursing, social work, occupational therapy and equipment services; and (iii) whether any assessment has been made that existing arrangements ensure seamless continuity of care for patients approaching end of life.

Patients discharged from hospital with palliative care needs should continue to receive coordinated support across services. There are established discharge planning processes which require that a patient’s ongoing care needs are assessed prior to discharge, and that appropriate referrals are made to relevant community services based on clinical need. This includes referral to community nursing teams, social work, allied health professionals and community specialist palliative care, as appropriate.

The processes in place to notify community services rely on multidisciplinary discharge planning at ward level and clinical judgment to ensure that the appropriate referrals are made to community-based services.

Where patients are identified as having palliative care needs prior to discharge, a referral should be made to the district nurse for a holistic needs assessment. Where a patient is known to be in the dying phase of their illness, the regionally agreed Home for the Last Days of Life pathway should be followed when the discharge is being planned.

With the roll out of Encompass, work is ongoing across the Health and Social Care system to strengthen these processes through the use of a Palliative Care FYI flag.

My Department is aware of the current challenges in timely communication of palliative and end of life care information between care settings and there is ongoing engagement with Health and Social Care Trusts and partners in this regard.