SHROPDOC

1. To care for and treat the patient in the right place with no unnecessary delay or discomfort, by a responsible and empowered workforce

2. 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

3. 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, • Urgency at various stage dictates response times, • Call handlers and triaging clinicians under one roof Clinicians, GPs & nurses Team leaders and despatchers Call handlers Primary Care Centres

4. 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,

5. 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,

6. 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

7. 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,

8. 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

9. 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