Community Hospital Review – The Clinical Model What did we recommend?

Dr. David Carson, Director, The Primary Care Foundation

Opportunities in new integrated trust

• Draw on larger pool of expert community nurses • Increase links to general practice and community staff • Blur the boundary between the community and hospital care • Potential economies of scale across the five hospitals © Primary Care Foundation

Good clinical practice

• Patients should not have delays waiting for decisions • Evidence shows rapid senior decisions result in better outcomes: suggest daily ward rounds with medical and rehabilitation goals reviewed every morning (advanced nurse practitioner (ANP), and/or GP, and nurse and discharge coordinator present ) decision making at start of day • Aim for consistent and regular expert clinical input • Once per week is not adequate - ensure consultant ward rounds are twice a week and senior clinician – either Consultant or GP with a specialist interest (GPsi) leading the multidisciplinary team (MDT) • Expertise needs to be maintained at weekends and out of hours – potential to increase therapy input at weekends to facilitate discharge © Primary Care Foundation

Principles … 1

• Establish a common set of competencies across all units • These should be sufficiently flexible to encompass local variation in admissions and case mix (GP direct admissions) • Affordable • Builds on existing strengths © Primary Care Foundation

Principles … 2

• Builds on staffing resource in wider trust • Allows a process of continual decision making and review • Delivers baseline competency and expertise 24- hours every day • Takes account of local availability of staff © Primary Care Foundation

Overall description of clinical model

• Consultant leadership and review twice weekly across all wards • GP expert input to all wards daily • Advanced Nurse Practitioner (ANP) cover all wards 9 - 5 Monday to Friday • Weekends, evenings and overnight ANP on call for all wards supported by medical on-call rota (Trust assumes full responsibility for cover out of hours) © Primary Care Foundation

Consultant role

• Overall responsibility • At helm of early senior decision making – responsible for setting clear management plans and rehabilitation goals with the multi-disciplinary team (MDT) – they must be present at MDT • Clinical leadership and mentoring – provide source of expert advice to all personnel especially ANP and GP • Responsible jointly for length of stay and other key quality indicators with ward manager / part of clinical governance framework • Twice weekly presence on the ward – maintained despite on call commitments at acute hospital © Primary Care Foundation

GP role

• Expertise in care of older people • Career development, training and mentoring • Responsible for daily decision making and progress of rehabilitation assessment • Build on existing expertise and roles across community hospitals • Long term commitment from staff and trust © Primary Care Foundation

ANP role … 1

• Daily presence to support care of patients starting with Board Round with other staff ( eg therapist / discharge co-ordinator ) at start of day • Assessment and Prescribing ( we expect ANP to have core competencies – e.g. clinical assessment of patient; basic diagnosis-making, e.g. chest /urine infections; management of common scenarios, e.g. fever , hypoxia , hypotension, hypoglycaemia, confusion, GI bleed etc. ) • Assessment on daily basis with decision making on daily basis © Primary Care Foundation

ANP role … 2

• Progress actions, assessment, investigations and therapies so that goals are reached in expected time and problems identified early • Ensure individual patients care plans are progressed. Ensure ANP is able to ask for senior advice at any time, so decisions are not delayed • Ensure robust clinical governance system is in place © Primary Care Foundation

Implementation

• Commissioners used findings from our study to develop a specification in cooperative discussions with the trust • Trust and commissioners now have the same goals • Everyone underestimated the focus needed for implementation © Primary Care Foundation