Step 3 - Co-ordination of care

Once a care plan has been agreed, co-ordinating all of the relevant services is essential to ensure the person's needs and preferences are met.

If a  holistic assessment has been carried out and shared appropriately, it should be possible to co-ordinate care for the individual, their family and carers. This effort may need to involve local primary, community and acute care providers, ambulance and out-of-hours services, social care, hospices and transport services.

Tools to help include:

• The  national information standard for end of life care co-ordination (ISB 1580), which sets out the core data items that need to be recorded and shared
• Electronic Palliative Care Co-ordination Systems (EPaCCS) - a means by which information can be shared across care settings
• e-ELCA e-learning modules on integrated learning and a unified DNACPR policy, free for health and social care staff
• NHS Continuing Healthcare
• Unified  Do not attempt cardiopulmonary resuscitation (DNACPR) principles.

Case studies relating to Step 3 of the care pathway.