Hardwick Clinical Commissioning Group 1. Outlier for emergency admissions Care of frail elderly and patients with complex needs reactive and uncoordinated.

Hardwick Clinical Commissioning Group

1

Outlier for emergency admissions Care of frail elderly and patients with complex

needs reactive and uncoordinated Figures 07-08:

◦ SAR all ages 107◦ SAR 65+ 116.3◦ Readmissions within 28 days: all ages 10%;

65+ 13.4%


2

Visited Croydon to look at their Virtual Ward model

Aware of Unique care model introduced at Shires

Wanted to build on the good work CM already doing

Work in a more integrated way with DN team and

Acute care


3

Embedded in Primary Care

Adopted principles of Unique Care: case

management; integrated working with SS and

joint assessments

CM lead professional

Close working ICS, SN, Palliative care


4

Care co-ordinator as Ward administrator

Integrated working with DN team

GP Champion

VW Process Flow Chart

Patient Leaflet

Practice Leaflet


5

Mr B. 79yr old man with COPD, Bladder Cancer, Pernicious Anaemia,

Pneumoconiosis

Home visit because of swollen ankles, increasing SOB, declining mobility.

LTOT but sats only 78% on air increasing to 85% on 4L O2. Impn Cor

Pulmonale. F/U with Home Oxygen Team chased. Commenced on

Furosemide and increased ventolin dose. Referred for ECHO and to VW as

assessed to have complex needs and to be at risk of admission

S/B CM and SW on joint visit – paper work and appt arranged by CC

6


Clinical care under review by CM. Support from SS declined at the

moment but SW now familiar with situation so when deteriorates

can organise support quickly. When seen by Steve Collis for O2 assessment unwell and sats not

recovering. Organised admission. In hospital over night and advised that there was nothing else that they could do for him.

CM has had several visits to the house over the last 2-3w. Has discussed preferred place of care/DNAR etc. Rightcare completed. Will review ECHO when available and liaise with GPs re future management. DNs aware of the situation as will be involved in EoL care.

7


8


Joint working with SS – mutual learning

experience. Access to each others records

invaluable.

In reach into Acute Care – Matron to Matron

discussion. Supported by joint matron forum.

Rightcare

Improved EOL/Advanced care planning


9

Joint working with DN team

Care co-ordinator – co-ordinates ‘intelligence’

and maintains board with list patients in hospital

Evaluation demonstrated excellent patient and

staff satisfaction.

‘Bucked’ the trend for emergency admissions for

Derbyshire


10

“Everyday tasks have been much easier”

“Nice to be able to talk about Dad’s medical problems”

“Peace of mind for the family”

“I have a more positive attitude”

“I know that help is near if required”

“The service provided is first class”

“It’s easier by not having to get to the doctors or go into

hospital”

11


It has had the following influence on my work:-

Better understanding of complex care management

Improved ease of accessing appropriate medical and

social support for patients with complex needs

Tracking patients is useful

Improved continuity of care

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Consider rolling out the model across all practices –

model modified to specific area

Build on current in reach work to achieve full

Integrated care – e.g. Matron Forum

Facilitate early discharge from Acute Care

Expand specialist support in the community e.g.

Community Geriatrician, Support Worker for Dementia


17

Hardwick Clinical Commissioning Group 1. Outlier for emergency admissions Care of frail elderly and patients with complex needs reactive and uncoordinated.

Documents

clinical care

integrated care

primary care

eol care

acute care matron

principles of unique

joint working

joint matron forum