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Commissioning alternatives to hospital. Dr Seth Rankin Rob Persey. Structure. Introduction to the Community Ward in Wandsworth. Platform for other admission diversion schemes. Not just health and social care – everybody’s responsibility!. What is a Community Ward?.

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Presentation Transcript
  • Introduction to the Community Ward in Wandsworth.
  • Platform for other admission diversion schemes.
  • Not just health and social care – everybody’s responsibility!
what is a community ward
What is a Community Ward?
  • A new way to structure Community Service.
  • Multidisciplinary Platform

for providing integrated health & social care in the community.

  • Towards developing a comprehensive service designed to deliver acute & chronic healthcare at home.
an analogy
An Analogy…


Acute & Chronic Patients

A&E, MAU, Inpatient, etc

MDT Ward Rounds

Bedside & Paper



Social Workers


MDT input…

Community Wards

Acute & Chronic Patients


MDT ‘Ward Rounds’


Nurses– CMs, ANPs, DNs

Doctors– GPcw, Geriatricians

Social Workers


MDT input – Mental Health, Palliative Care, Specialist Nurses, Addiction Services, Age UK, Carers

why have a community ward
Why have a Community Ward?

Improve patient’s experience and increase capacity for home-based healthcare

Reduce unnecessary admissions.

Assist integration, productivity & responsiveness of community services.

Platform for Integration of Social and Health Services.

Care often not equitable across an area.

To prevent admissions and facilitate discharge we need to provide a safe place for patients to go.

the basics
The Basics:
  • Daily ‘activity rounds’ with core team
  • Weekly MDT ward rounds with ‘everyone’
  • Joint visits (GPcw, CM & SW) for ‘chronic’ patients
  • ANP or GPcw visits for ‘acute’ patients
  • In-reach into hospitals to facilitate early discharge
  • Patient information entered directly into GP’s computer (EMIS) via remote connection


Key elements



Community Matrons


Integrated IT

(EMIS, iClip, Framework i)


Ward Clerk

(Core Team)

Social Worker

• DNs • ICT • Specialist Nurses

• Mental Health • Dementia Addiction • AgeUK • Palliative

...and more

Patient Pathways:

Community Ward



(IP or OP)

Ward Clerk

  • Acute Intervention
  • ANP
  • GPcw








  • Chronic Management
  • Community Matron
  • GPcw
  • Social Worker



Predictive Modelling

Voluntary Services


lessons learned
Lessons Learned:
  • Patients prefer to be at home.
  • Massive duplication of services in the community.
  • MDT meetings & integration help address this.
  • Integrating with Social Services is enabled by MDT meetings.
  • GPs can be useful.
  • ‘Ward Clerk’ role is vital.
  • IT integration can be cobbled together.
  • None of this is easy.
  • Ongoing Funding linked to Evidence of Effectiveness.
  • Transition from Pilot to Establishment.
  • Staffing levels difficult to maintain – CMs & GPs.
  • Line Management Structure & Systems.
  • Project/Change Management resources.
  • IT integration – technical difficulties & lack of will.
  • Predictive Modelling.
  • Rooms & Estates Issues.
  • Internal ‘marketing’ – hearts & minds of existing staff.
  • External ‘marketing’ - GPs, Secondary Care, Social Services, Ambulance, OOH providers, voluntary sector.
exploring other admission diversion schemes
Exploring other admission diversion schemes
  • Developing an integrated assessment and response service (IARS):
    • Improve transition for patients between hospital and community services
    • Reduce acute hospital activity, including unnecessary admissions
    • Maximise independent living to support people ‘to do’ rather than ‘be done to’
    • Reduce and delay admissions into residential/nursing care
    • Develop dementia friendly services
iars what s in scope list not exhaustive
IARS – what’s in scope? (list not exhaustive!)
  • Community Ward as platform for other interventions:
    • Reablement and Intermediate Care
    • Telecare and telehealth services
    • Equipment
    • Integrated Falls Service
    • Community Therapies
    • Out of Hours service
    • Specialist Day Services
3 workshop questions
3 workshop questions ?!?! …
  • Practically how do we implement this on the frontline – can it work as a platform for integrated health and social care delivery?
  • Will we ever realistically see a reduction in hospital admissions?
  • (How) can we facilitate the transfer of resources from the acute to the community sector?