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Baseline Model of care for proposed community wards

Appendix 1. Baseline Model of care for proposed community wards. Pyramid of care & care functions. Components of Community wards. Common referral processes. Discharge. Care status and service response. Care function. Care status. Hospital.

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Baseline Model of care for proposed community wards

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  1. Appendix 1 Baseline Model of care for proposed community wards

  2. Pyramid of care & care functions Components of Community wards Common referral processes Discharge

  3. Care status and service response Care function Care status Hospital Community Wards, including use of Independent Sector Nursing Homes Primary & Community services Self care with Local Health & Wellbeing resources

  4. Components of the Community Ward

  5. Proposed Community Ward Model Acute Hosp. R,R&R Acute community Ward (HDU) GP Ward Team Admin Community Matrons M H R e h a b L T C E o L E L D E R L y Ward management/ Neighbourhood team Social Care Self Care

  6. Community Ward Team Responsibilities RR&R named nurse linking directly with neighbourhood team named nurse, managing the most acutely unwell, then transferring into ward Ward admin leading on the admission and discharge process, linking with named nurses, GPs and community matrons Community matrons leading on the clinical support for the team, managing their caseload and the capacity of the service

  7. Community Ward Team Responsibilities Neighbourhood team to include therapies, and leads within specialist areas- End of Life, Mental health, long Term Conditions, Care of the Elderly and Rehab. GP Clinical leadership for the ward/team, providing medical cover and support. Referring directly into team. Social Care Directly linked/named social care support, working closely with named nurses and community matrons

  8. Community Ward Core Teams 7 days a week service with an out of hours service of 10 pm – 7am Clear discharge plan agreed at admission

  9. Common referral process

  10. Discharge

  11. Community Ward Out of Hours service

  12. Locality Teams & other local links

  13. Specialist Community Services Services across 4 Localities and 7 Community Wards

  14. Access to Hospital Services & Hospital out reach

  15. Community Ward Enablers • Shared protocols. • Referral process. • Case Management. • Access to Equipment. • Long Term Care Database. • Transport into and out of A&E departments- reducing reliance on Ambulance Services. • Closer links with GP in A&E- RR&R nurses based alongside, timely Communication to prevent admission.

  16. Close links with Out of Hours services and Ambulance services to prevent admissions. 7 day working for all professions. Capacity management methodology to move resources to where it is required, based on the demand, to include out of hours community provision. Telehealth to support those with chronic condition and prevent deterioration. RiO in community service to improve communication between services – links required to GP, acute and Social Care systems. Access to timely diagnostic results, allowing community clinicians to make swift decisions for the management of the person. Community Ward Enablers

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