Jean Hendry Health Care Manager, Communities and Partnerships NHSA&A

1. Jean HendryHealth Care Manager, Communities and PartnershipsNHSA&A Community Ward Integrated Care and Enablement Service

2. 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.

3. Who is in the team? 3 teams of three staff, in East, South and North Ayrshire, funded by Change Fund, comprising: GP Advanced Nurse Practitioner Ward administrator Established August 2012, working Monday to Friday

4. 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

5. Initial assessment at homeIdentifying the right patients who would benefit

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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 needs. 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

12. Actions 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 DNA CPR.

13. Now Self managing his exacerbations Alcohol- 1-2 cans beer/day Driving! No care package! Good relationship with family No further hospital admissions.

14. Intermediate Care and Enablement Service Short term, community based service to prevent admission and support early discharge.

15. WHAT DO WE DO? 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

16. 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

17. 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 ICES MANAGER NORTH ICES 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. SOUTH ICES 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 WHO DOES IT?

18. Activity April 12 – March 13

19. 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

20. COMMUNITY HUB SECONDARY CARE Acutely ill Patient NHS 24 Intermediate Care & Enablement Service Chronically ill Patient PRIMARY CARE TEAM SPOC SOCIAL SERVICES AHPs Pharmacy OT Specialist Nurse Private and Voluntary Sector Social Work HUB GP Multiple/Complex Social-needs Patient Practice Nurse District Nurse Community Wards ADOC SPARRA Patient (All Ages) AYRSHIRE HOSPICE CARERS (Kinship / Professional)

21. SustainabilitySMART Integrated services ICES Team Joint Working Specialist Universal Community health & social care services