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Walsall

Walsall. Interface With Secondary Care. Trish Skitt 13, Nov 2003 Birmingham Evercare Event. Agenda. PCT and Secondary Care Background Business Case Scenarios Secondary Care Interfaces Notification of hospital admission APN and consultant mentoring HAT tool process

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Walsall

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  1. Walsall Interface With Secondary Care Trish Skitt 13, Nov 2003 Birmingham Evercare Event

  2. Agenda • PCT and Secondary Care Background • Business Case Scenarios • Secondary Care Interfaces • Notification of hospital admission • APN and consultant mentoring • HAT tool process • Monthly business/clinical meetings • Most challenging and support for change in implementing Evercare programme in Walsall • Discussion

  3. PCT Background • 1700 Employees • 255,000 population • 14% (41,422) > 65 years old • 121 GPs total in community • High number of single-handed GPs • 36 GPs (11 GP Practices) involved in Evercare • 1 primary hospital-785 beds • Incorporate MH • Star Ratings

  4. Secondary Care Background • 90% of Walsall patients go to this hospital • Focused on reduction of avoidable hospital admissions • 3.36% of the high risk >65 drive 46% of unplanned admissions • Director of Nursing and consultants support • IT initiative to link all systems together

  5. Possible impact?

  6. What’s in it for Secondary Care? • Managing capacity • Meeting targets • More effective utilisation of geriatrician consultant time • Discharge planning • Shared learning • Coordinated diagnostic/medication management • Knowledge of patient’s pre-hospital status • Interface of primary and secondary care

  7. Hospital Notification Process • System-wide IT Initiatives • Fusion Project • PMS Access • Status Messaging • Evercare cohort list/APN sent to hospital IT • Automatically notifies APN of hospital attendance • email • mobile phone

  8. APN and Consultant Partnership • 4 nurses paired up with 4 Geriatric Consultants • Visit and conduct wards rounds together • Good hospital support for documenting notes in hospital medical record • Work in partnership with discharge planning team to streamline LOS and share learning

  9. Partnership Success Stories • Admission Avoidance • APN called consultant who made a domiciliary visit • Nurses confidence • Averted hospital admissions • Shortened length of stay • Enhanced quality of life • Increase in functional status • Pharmacy Management

  10. HAT Tool Process • Started process in Sept • Multi-disciplinary team • Chaired by Clinical Lead • Consultants, GPs APNs, Social Services • Team meets monthly to discuss Evercare cohort admissions and determine root cause • Shared learning • Action plans created • Will categorize admissions monthly to trend

  11. Monthly Business Meetings • Team of clinical and management • Shared agenda • Shared success stories • Communicate data results (once available) • Issues/barriers • Future actions

  12. Most challenging aspects implementing the Evercare Programme • Modernisation agenda of PCT/Secondary Care • Supporting framework • ‘Not more of the same’ • Engaging critical mass of GPs • Confidence for service re-design • Primary Ownership Milestone

  13. Supporting the Change • Level of local commitment/leadership • Commissioning function • Quality of patient care • Audits • Support and enthusiasm of Evercare team • PCT structures mirror national strategy • Assists whole systems approach • Person Centred Care • NSF • Enthusiasm, skills, confidence of appointed nurses • Communication of patient diary events

  14. Questions/Discussion

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