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Jean Hendry Health Care Manager, Communities and Partnerships NHSA&A. Community Ward Integrated Care and Enablement Service. Community Ward.

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jean hendry health care manager communities and partnerships nhsa a

Jean HendryHealth Care Manager, Communities and PartnershipsNHSA&A

Community Ward

Integrated Care and Enablement Service

community ward

Community Ward

The Community Ward model delivers intensive support to patients in the community through targeted co-ordination of care and anticipatory care planning, for patients with complex long-term conditions who are at increasing risk of unplanned hospital admissions.

who is in the team

Who is in the team?

3 teams of three staff, in East, South and North Ayrshire, funded by Change Fund, comprising:


Advanced Nurse Practitioner

Ward administrator

Established August 2012, working Monday to Friday

patient selection

Patient Selection

Patients> 18 years of age & vulnerable to admission. Benefit from ACP

Long Term Conditions eg COPD, Heart Failure, Diabetes, Recurrent UTI/Infection & Falls,

General practice selected from SPARRA list

Consent required from GP& Patient

Referral from Acute physicians and via Acute Ward Rounds and discharge protocols

patient pathway

Weekly MDT meetings

  • Daily ward rounds with GP, ANP & Ward Administrator
  • Information entered directly into GP records
  • Out patient investigations, diagnostics, visiting schedules & information flow co-ordinated by ward administrator including access to records
  • Anticipatory Care Plan for all patients
  • Regular ongoing care of patient at home
  • Patient encouraged to contact CW when unwell
  • Length of stay can be several weeks, months or longer

Patient Pathway

activity data july 2013

224 referrals received by Community Ward

- 62 East

- 75 North

- 87 South

  • 91 patients currently on Community Ward
  • 64 patients discharged from Community Ward
  • 63 referrals were not accepted

At present not reaching target activity of 100 patients per ward

Activity Data -July 2013

community ward evaluation

Community Ward Evaluation

led by Department of Public Health

Stage 1 (Jan-May 2013): Initial emphasis on process evaluation – service processes & outputs

Stage 2 (Jun-Sept 2013): Incorporating outcome evaluation - key service outcomes

stage 1 findings

Stage 1 findings

Evidence of early successes

prevention of avoidable admissions

positive feedback from patients and families

Increasing buy-in from other professionals

CW has potential to improve efficiency and increase number of patients/caseloads

key areas for improvement

Key areas for improvement

Improved inclusion criteria and referral routes to increase the appropriateness of referrals and reduce non accepted patients

More focus on referrals from secondary care to bring the number of patients being referred into the Community Wards closer to the intended level.

Improved integration between the Community Wards and partner services, such as ICES and ADOC.

Focus on 24 hour care, linking to OOHs.

community ward patient story

Community ward – patient story

Patient aged 67yrs

109 days in hospital in previous 12

Months (alcohol and COPD)

GP/acute unable to change pattern of care


Joint visit Social worker and Community

Ward GP and nurse while patient was an in-patient in Crosshouse.

Identified issues as housing, lack of family contact,

bereavement, alcohol and poor management of COPD



1. Social work arranged for Sheltered Housing near his family.

2. Family decided to look after his finances and support limiting alcohol intake.

3. Management plan for exacerbations COPD with rescue medications in the house.

4. Welfare POA arranged with both sons and patient decided he wanted a




Self managing his exacerbations

Alcohol- 1-2 cans beer/day


No care package!

Good relationship with family

No further hospital admissions.

intermediate care and enablement service

Intermediate Care and Enablement Service

Short term, community based service to prevent admission and support early discharge.



Alternative to Hospital Admission

Early/Supported Discharge from Hospital

  • Rehabilitation Pathway
  • Frail Elderly Pathway - Links with Consultant Geriatricians and Day Hospitals
  • Falls Pathway - Falls Screening Service
  • Early Supported Stroke Pathway
  • Assessment & Rehabilitation Beds

Where we came from

Where we are now

  • East Ayrshire
  • IC&ES, Kirklandside Hospital /
  • East Ayrshire Community Hospital, Cumnock
  • North Ayrshire
  • IC&ES, Bridgegate House, Irvine /
  • Brooksby, Largs
  • (aligned with reablement service / SPOC for homecare
  • South Ayrshire
  • IC&ES, Biggart Hospital, Prestwick /
  • Girvan Community Hospital
  • (linked with local authority enablement service)
  • East Ayrshire
  • Rapid Response Service, Crosshouse Hospital
  • Home from Hospital Homecare, Crosshouse Hospital
  • Community Alarms, Ross Court, Galston
  • Intermediate Care, Ross Court, Galston
  • North Ayrshire
  • Rapid Response Service, Crosshouse Hospital
  • Hospital Discharges Homecare, Crosshouse Hospital
  • Ayrshire Reablement Team, Ayrshire Central Hospital
  • South Ayrshire
  • Rapid Response Service, Ayr Hospital
  • Integrated Care Team, Ailsa Hospital
  • Enablement Service, Local Authority

EAST ICES (Joint Health and LA managers)

Team Leader (Community & Assessment Rehab Nurse) x 1.0 wte

Physiotherapy x 3.5 wte

Occupational therapy x 3.3 wte

Comm Assess & Rehab Nurse x 2.0 wte

Pharmacy x 0.8 wte

Dietitian x 0.5 wte

Care Manager x 1.0 wte

Homecare Manager x 2.0 wte

Support Assistant x 7.0 wte

Technical Instructor x 2.07 wte

Falls Technical Instructor x 1wte

Rehabilitation Assistant x 4.0 wte

Administration x 5.3 wte

Carers x 27wte Response Team x 30wte



Team Leader (Physiotherapist) x 1 wte

Physiotherapy x 1.5 wte

Occupational therapy x 3.5 wte

Community Assess & Rehab Nurse x 2.8 wte

Pharmacy x 1.0 wte

Dietitian x 0.5 wte

Social Work Assistant x 1.0 wte

Technical Instructor x 2.47 wte

Falls Technical Instructor x 1.0wte

Administration x 3.5 wte

Carers are accessed from the local authority Reablement service.


Team Leader (Community & Assessment Rehab Nurse) x 1.0 wte

Integrated Care Practitioner x 1.0wte

Physiotherapy x 3.5 wte

Occupational therapy x 2.8 wte

Community Assessment & Rehab Nurse x 2.0 wte

Pharmacy x 0.8 wte

Dietitian x 0.5 wte

Technical Instructor x 3.0 wte

Falls Technical Instructor x 1.0 wte

Income Maximiser x 1.0 wte

Administration x 3.35 wte

Carers x 4.48wte



April 12 – March 13

picking up the pace
Picking up the pace
  • Integrated, community based intermediate care service comprising CW and ICES (from Sept 2013)
  • More flexible and responsive to GP and acute needs
  • Working across whole patient pathway in acute and community
  • Part of future integrated health and social care service

Need to secure funding on permanent basis

to stabilise staffing and service plans




Acutely ill Patient

NHS 24

Intermediate Care & Enablement Service

Chronically ill Patient







Specialist Nurse

Private and Voluntary Sector

Social Work



Multiple/Complex Social-needs Patient

Practice Nurse

District Nurse

Community Wards


SPARRA Patient (All Ages)


CARERS (Kinship / Professional)

sustainability smart integrated services
SustainabilitySMART Integrated services


Joint Working


Universal Community

health & social care services