Transcript Slide 1
To care for and treat the patient in the right place with no unnecessary delay or discomfort, by a responsible and empowered workforce SHROPDOC • Cooperative created in 1996, • Out of hours primary care services (PCCs) for 600,000 population, • Urban areas to extreme rurality, area over 3,500 sq miles • 300 local GP members • 200 other staff including 30 senior nurses • Not for Profit organisation • Clinically led The Out Of Hours Process • Process: – Patients incoming calls handled by non clinicians (@150k calls per year), – GPs and nurses call back patients for tel. triage, – Outcome: • Advice over the telephone, • Face to face: base appointment or home visit, Clinicians, GPs & nurses Team leaders and despatchers • Urgency at various stage dictates response times, • Call handlers and triaging clinicians under one roof Primary Care Centres Call handlers LTC patients: sharing Information, facilitating access Sharing information for better care: • • OOH events of care passed onto GP surgeries by 08h00 next working day, Day time GPs flag LTC (palliative care, mental health condition) patients, • 10,194 special patient notes, • Care plans and DNR, • Emergency Action Plan (partnership with Shropshire local authority) for adults with learning disabilities, Facilitate access to vulnerable patients: • In partnership with VISS: support deaf, and hard-of-hearing patients, LTC patients: treatment & monitoring • In all PCCs: extensive equipment and exhaustive formulary, • Syringe drivers, • Nebulisers, • Controlled drugs, • Support national & local initiatives • Just In Case Box: Palliative Care Patients, • Initiate Home Oxygen Therapy, • Telehealth: • support Community Matrons • 70 patients using Florence, mobile phones and devices for physiological measurements, OOH Shropshire Community Nurse / SCN • • • • • • • County wide service, 7 days a week, 1900 to 2400, Senior community nurses with specialised training in LTC, Continuity of care handover “from and to” day teams, Can do culture, Among other interventions: • Catheterisation, • Abnormal INR treatment, • Palliative care, • COPD, • Diabetes Care Coordination Centre • • • • • • Single of point access for GPs & other clinicians, Enabling increasing number of patients to be looked after in their own homes, Highly experienced senior nurses with primary care and secondary care background, and significant LTC knowledge, Coordinate the most appropriate care pathways for patients, Facilitate smoother journey throughout primary care and secondary care, Existing pathways; examples with emphasis on LTC: – – – • COPD: links with specialised respiratory nurse teams, same day assessment, Oncology helpline, Abnormal INR, Driving pathway developments with emphasis on LTC: – – – Diabetes, Palpitation, Ascites malignant and non malignant, Physiotherapy Triage Service • Referrals direct from GPs • Telephone Triage – advice, assessment and management • Self care or onward referral • Patients gain ownership of problem • Action whilst on waiting list, not delay • Experienced working physiotherapist, highly qualified working with Best Practice Guidance Other services • Falls – central hub for referral to Falls Prevention Programme • Help 2 Quit • Night Sitting Service • Immediate Care referral hub • Lone Worker/Severn Hospice Monitoring • Weight Management Service • Step Up/Step Down Bed Management