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?

• 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…

Hospitals

Acute & Chronic PatientsA&E, MAU, Inpatient, etc

MDT Ward RoundsBedside & Paper

Nurses

Doctors

Social Workers

Pharmacists

MDT input…

Hospitals

Acute & Chronic PatientsA&E, MAU, Inpatient, etc

MDT Ward RoundsBedside & Paper

Nurses

Doctors

Social Workers

Pharmacists

MDT input…

Community Wards

Acute & Chronic PatientsHome-based

MDT ‘Ward Rounds’Paper-based

Nurses – CMs, ANPs, DNsDoctors – GPcw, GeriatriciansSocial Workers PharmacistMDT input – Mental Health,

Palliative Care,

Specialist Nurses, Addiction Services,

Age UK, Carers

Community Wards

Acute & Chronic PatientsHome-based

MDT ‘Ward Rounds’Paper-based

Nurses – CMs, ANPs, DNsDoctors – GPcw, GeriatriciansSocial Workers PharmacistMDT input – Mental Health,

Palliative Care,

Specialist Nurses, Addiction Services,

Age UK, Carers

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:• 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

Integrated IT (EMIS, iClip, Framework i)

GPcwSocial

WorkerPh

arm

acist

ANPCommunity Matrons

• DNs • ICT • Specialist Nurses • Mental Health • Dementia Addiction

• AgeUK • Palliative...and moreGeriatricians

Ward ClerkWard Clerk

Predictive Modelling

SecondaryCare

(IP or OP)

GP

SPoC

Chronic Management

• Community Matron• GPcw

• Social Worker

Community Ward

Acute Intervention

• ANP• GPcw

Patient Pathways:

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.

Challenges:

• 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 • 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!)• 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 ?!?! …

• 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?