Transcript Slide 1
Appendix 1 North Somerset Baseline Model of care for proposed community wards North Somerset Pyramid of care & care functions Components of Community wards Common referral processes Discharge Care status and service response North Somerset Care function Care status Hospital Acute condition Community Wards, including use of Independent Sector Nursing Homes Unstable long term condition or exacerbated episode Primary & Community services Stable long term conditions or simple episodic care Self care with Local Health & Wellbeing resources Self managing chronic condition Components of the Community Ward North Somerset Locality Teams Shared Specialist community based teams Core Community Wards Teams Out of hours service Rapid access to agreed Hospital services/ Hospital out reach Proposed Community Ward Model Acute Hosp. North Somerset Acute community Ward (HDU) R,R&R GP Community Matrons Ward Team Admin Social Care M H R e h a b L T C E o L Self Care E L D E R L y Ward management/ Neighbourhood team Community Ward Team Responsibilities North Somerset RR&R named nurse linking directly with neighbourhood team named nurse, managing the most acutely unwell, then transferring into ward Ward admin leading on the admission and discharge process, linking with named nurses, GPs and community matrons Community matrons leading on the clinical support for the team, managing their caseload and the capacity of the service Community Ward Team Responsibilities North Somerset Neighbourhood team to include therapies, and leads within specialist areas- End of Life, Mental health, long Term Conditions, Care of the Elderly and Rehab. GP Social Care Clinical leadership for the ward/team, providing medical cover and support. Referring directly into team. Directly linked/named social care support, working closely with named nurses and community matrons Community Ward Core Teams North Somerset Clinical team leader, ward clerk, community ward sisters, GPs, therapists, generic support workers, and social workers 7 core teams based within 4 existing localities with total capacity of c.280 patients at any one time Daily reporting on c.5 most ill patients Open 7am to 10pm for full service provision Weekly reporting on c.35 patients 7 days a week service with an out of hours service of 10 pm – 7am Clear discharge plan agreed at admission Common referral process North Somerset Single point of access called (protocols also agreed with Ambulance Service) Person not known to Locality Teams Person known to current Locality Teams Admission to hospital Criteria base assessment completed by professional (urgent or routine) Admission to community ward and patient pathway commences Initial telephone triage Assessment requested (urgent or routine) Primary/Community Locality Teams management) Other support solutions identified No further action required / appropriate signposting Discharge North Somerset Patient Planning • Discharge care/ intervention plan shared with patient and family • Each patient will have goal driven plan and when achieved the patient can be discharged • Discharge/ transfer date set on admission • Community Ward team will be the professionals who will plan the discharge via ‘ward round’ methodology • Discharges can happen 7 days per week • A Key Worker produces and signs off discharge and Organisation agreement on future reviews Community Ward Out of Hours service North Somerset Operational hours Services Links • 10pm to 7am • Urgent assessment and treatment • Emergency assessment and referral for 999 • Diagnostics • Planned health care interventions • Planned sitting service • Low level reassurance to patients with LTC (and their carers) in their own homes. • Carelink • Carers Emergency Response service Locality Teams & other local links North Somerset 4 existing locality teams including community nurses, matrons, social workers and linkages with primary healthcare teams and community pharmacists Generic services, end of life care, wound dressings, continence, falls, dementia, IV’s, assessment and neuro. Linkages with primary care teams 60 patients capacity (monthly review) Linkages with community pharmacy Specialist Community Services North Somerset Services across 4 Localities and 7 Community Wards Rapid Response & Rehabilitation Specialist Diabetes Nursing Community Occupational Therapy Community Pulmonary Community physiotherapy Musculoskeletal Disabled Adult Resource Team Community Hospital inpatient beds Podiatry Speech & Language Therapy Stroke Specialist Nurse Continence and Enuresis Tissue viability Dietetics Falls Prevention Gastrointestinal endoscopy Access to Hospital Services & Hospital out reach Hot clinics/ Consultant advice Diagnostics Specialist nurses/ North Somerset Community Ward Enablers North Somerset Shared protocols. Referral process. Case Management. Access to Equipment. Long Term Care Database. Transport into and out of A&E departments- reducing reliance on Ambulance Services. Closer links with GP in A&E- RR&R nurses based alongside, timely Communication to prevent admission. Community Ward Enablers North Somerset Close links with Out of Hours services and Ambulance services to prevent admissions. 7 day working for all professions. Capacity management methodology to move resources to where it is required, based on the demand, to include out of hours community provision. Telehealth to support those with chronic condition and prevent deterioration. RiO in community service to improve communication between services – links required to GP, acute and Social Care systems. Access to timely diagnostic results, allowing community clinicians to make swift decisions for the management of the person.