Download 1.2 COMMUNITY DELIVERY TEAM PACK Draft v0 11

NHS Erewash Clinical Commissioning Group
COMMUNITY DELIVERY
TEAM
TOOLKIT
NHS Erewash Clinical Commissioning Group
1. OVERVIEW OF INTEGRATED CARE
Integrated Care is an innovative service aimed at providing coordinated care for
adults identified at high risk of hospital admission or admission to a care home
(for long or short term stay), who would benefit from a multi-disciplinary and
multi-organisational approach. Integrated Care in Erewash represents
collaborative working between key stakeholders to deliver effective planned and
unplanned care from health and social care organisations and also from other
services, e.g. therapies and mental health.
Community Delivery Teams (CDT’s) are responsible for managing planned long
term care through accessing services from primary care, secondary care,
community care, social care, mental health, out of hours and voluntary
organisations. Further information about each of the roles within the CDT team
can be found in the ‘Roles’ section of this pack.
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2. CORE ROLES WITHIN EACH COMMUNITY DELIVERY TEAM
GP
The CDT GP attends the weekly CDT meetings and provides medical advice as
required on individual patients, supporting all members of the team but in
particular the Community Matron. They provide ad hoc medical advice to the
Community Matron, District Nurse and the Social Worker about patients on the
case load if their usual GP is not available. In addition to this, they have the
following duties:
 Liaise with the usual GP regarding actions from CDT meeting or if patient
has no usual GP, arrange appropriate person to action decision and liaise
with that GP/clinician
 Liaise as appropriate with secondary care consultant looking after a patient
 Contact GP for consultants wishing to discuss a patient with the practice
unless they have a usual GP
 Provide a medical overview to the CDT
 Review, with the team, the risk stratification data and notes of patients
identified by the care co-ordinators as being at risk of admission.
Community Matron
Community matrons provide a service for people with multiple long term
conditions who are at high risk of hospitalisation. The aim of the service is to
provide proactive case management of patients with long term conditions in order
to enable them to stay in their own home and avoid unplanned, unnecessary
hospital admissions. Community matrons aim to provide better access to health
and social services as well as optimization of medication, regular monitoring
reviews and agreement of management care plans.
All community matrons have received training in advanced practice including top
to toe physical examination and pathophysiology of common conditions. In
addition to this they are non medical prescribers and have access to community
matron led beds in local community hospitals where they can admit patients who
require short term in patient care during an acute exacerbation of their condition.
Care Co-ordinator
The Care Co-ordinator is a pivotal role to the CDT and will be the interface
between service users, carers, primary care, secondary care, community care,
social care, mental health, out of hours and voluntary organisations. They will
have overall responsibility for the weekly CDT meetings and the smooth running
of integrated care within the team setting. The key role of the Care Co-ordinator
will be to schedule the weekly CDT meetings, manage the meeting agenda items,
ensuring that all new referrals are identified and information circulated to team
members in advance of the meeting. Please see Integrated Care Co-ordinator
specification for further information.
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Social Worker
The social worker will identify and respond to aspects of a person’s situation
that may be resolved either by utilising the persons own skills, contacts or other
assets, or by organising practical support from other organisations. The social
worker will contribute to the identification of situational risks to independence.
These might include loneliness, isolation, interpersonal relationships problems or
access to meaningful activity, which impact on wellbeing and the motivation to be
independent .The social worker will consider eligibility for DCC home care reablement service and in discussion with Delivery Team colleagues refer as
necessary.
The social worker will also provide information about DCC financial contribution
requirements to long term community or residential support (including respite
care). The social worker will also be responsible for the assessment that is
required to establish or adjust the personal budget which may be required to
purchase long term social support.
Practice Nurse
The Practice nurse will support the Care Co-ordinator and CDT by supporting
risk profiling and case selection from their practice patients. The practice nurses
will be offering their support and expertise in patient care and disease
management to the CDT as applicable under QOF or any other practice protocol
relevant to their practice registered patients.
The practice nurse will liaise with and volunteer and share any information
relevant to the patient care with the Care Co-ordinator, the lead GP or any
appropriate member of the CDT.
District Nurse
The Community Nursing service provides skilled, flexible nursing care to meet
the needs of individuals and carers in the community. Community Nursing Teams
have a specialist understanding of caring for people at home, who, because of
illness or disability, are unable to attend to attend surgeries or clinics for
assessment or treatment. The service is delivered in a caring and nonjudgmental manner in agreement with the individual and carer, taking into
account their physical, social, psychological, cultural and ethnic requirements.
To provide high quality nursing care, in the most appropriate setting to reduce
hospital admissions, promote quality of life, facilitate early discharges and
coordinate complex packages of care.
Occupational Therapists
Occupational Therapist’s aim is to promote and restore health, independence
and well-being in people of all ages, using purposeful occupation/activity.
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Occupation means any way in which the individual spends their time, for
example: in work, leisure and every day activities.
The Occupational Therapist will visit the individual at home, discuss any
identified difficulties and agree treatment aims.
The Occupational Therapist will do this by assessing the ability to complete
everyday tasks.
Following agreement with the individual, treatment may involve rehabilitation,
providing advice and information, equipment provision and referrals to other
agencies.
Physiotherapists
Community physiotherapists offer assessment, treatment and advice in people’s
own homes.
They see people with conditions such as falls, general mobility problems,
respiratory problems, Parkinson’s disease, stroke and MS.
The focus is on home exercise programmes to improve strength and balance, the
provision of appropriate walking aids to assist mobility, the management of
breathing problems, management of pain etc.
Care Team
Erewash care team work in partnership with Community Therapy services and
Social Services to provide the highest possible quality of care and services to
patients and their families 365 days per year.
The team will provide individualised flexible programmes of care to people within
their own homes.
Crisis situation up to 7 days - The service will support primary care teams
enabling a period of assessment, monitoring and review to be undertaken. This
will potentially avoid inappropriate admission to hospital, give time for a crisis
situation to stabilise and enable mainstream health and social services to
develop appropriate care packages to meet patient and carer need.
Palliative care for up to 6 weeks - The service will allow patient choice where
possible and support primary care teams to care for patients within their own
homes during the final few weeks of life.
Bereavement – The service will provide follow-up for carers/relatives of patients
that have passed away.
EREWASH FALLS PREVENTION SERVICE
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This service offers assessment for people who have fallen or who have fear of
falling. Physiotherapists and Occupational Therapists from the Falls Team, see
people in their own homes to assess their falls risk and offer advice and
treatment.
The Team’s roll includes:
•
•
•
•
•
•
•
Taking a detailed falls history
Assessing mobility, balance and muscle strength
Providing advice on home hazards
Discussing osteoporosis risk
Providing equipment for support
Helping to increase confidence
Providing home exercise plans
3. CARE PATHWAY
Erewash CCG in partnership with Derbyshire Community Health Services and
Adult Care are working hard on developing integrated care teams working in
localities to improve the care for people living in Erewash by providing joined up
and personalised health and social care services. The integrated care teams will
focus on delivering care for people with complex health and social care needs
who are at risk of hospital admission and significant deterioration in their health
and well-being. The model below illustrates the high level overview of the
Integrated Care Programme across Erewash.
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Colour code
Decision point
Tool/Criteria
Services
Supporting services
Referrer
p
Un
lan
ne
Pl
an
d
Requires care within 2 hours
or same/next day - to prevent
hospital admission (on referral
specify which to SPA)
Triaged to IC Team
ne
ia
er t
ri t e n
t c em
ee ag
t m an
no M
s se
oe a
D rC
fo
D
cr o e
ite s n
ri a o
fo t m
r S ee
PA t
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d
Requirement for a case
management approach
– prevention through early
intervention
SPA
Referral Criteria
Role of CC
- Case finding
- Risk strat
- MDT co-ord
Community
Delivery Team
Care Co-ordinator
Nomination Criteria
YES
Manage for
required period
CDT review
Allocate case manager
Nomination Criteria Score
determines bias
DN
team
Continual Assessment
Secondary Screening
Discharge/Refer
Practice
Acute
Trust
Social
Care
Personalised
Budgets
Therapists
CHC
Falls Service
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Appropriate for Case Management?
Community
Delivery Team
For
assessment
Specialist Nurses
Safeguarding Adults
YES
NO
Case
Manager
DN
team
Telecare
NO
Referrer
Social
Care
Or
signposting?
Personalised
Budgets
Telehealth
Dietetics
Self Care Programmes
DN Team
NO
Complex long-term If regular tasks
management or
required
safeguarding
Mental Health
(to incl. in model for Community
Delivery, RR and IC teams)
Equipment store
Short Stay/Respite
Social Care
Reablement
Therapies
Health
MDT - Rapid
Response
Care
Team
Routine Task
Manage for up
to 6 weeks
Non Critical
Critical <2hrs
Integrated Care Community Teams – N or S
Specialist LD team
GP OOH
(DHU)
Hospital Discharge
Social Care
Personalised budgets
Voluntary Sector
Place of Safety
Intermediate Care at Home
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4. INTEGRATED CARE TOOLS
4.1. Criterias and Assessment Tools
4.1.1 Referral Template for Health Care professionals to access the CDT
Referral Criteria: Over 65 with 2 or more of following:
Long term condition
Change/deterioration
Cognitive impairment
History of Falls
Care/Community Breakdown
Admission to hospital in last 12 months
Medication Issues
Patient Name:
_____________
DOB_________
Patient Address & Tel no_________________________
NHS No ______________________________
Reason for referral:
Any other relevant details:
Referring GP _________________________
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4.1.2 Health/Social Care Nomination criteria
Nomination Criteria for Complex Case Management:
Score
3
2
2
3
Adult over 18 years of age is/has:
Cognitively impaired – memory (any degree of loss), confusion (all levels)
Lives alone
Recently bereaved (major loss within 6 months)
Major caregiver for someone
A. Sub total score
Score
Social care specific
Score
Health care specific
4
Mobility problems requiring help from carer or
4
Diagnosed with 1 or more long term conditions which is
uses equipment (stick/frame/furniture/wheelchair,
unstable/unmanageable and highly impacts on daily living
etc.) - and this impacts on daily living
4
Environmental impact affecting daily living –
4
2 or more A&E visits or unplanned hospital admissions within
requires support to make living space more
the last 12 months
habitable/other
3
Emotional needs impacting on daily living –
3
Currently taking 8 or more medications
Suicidal, Miserable, Scared, Unhappy, Lonely, etc
3
Carer situation has significantly changed, for the
3
Has had a major change in treatment within the last 30 days
worse
B. Sub total score
C. Sub total score
Total Score (A+B) or (A+C)
A Total Score of 11 or greater, would trigger Health Risk Assessment (HRA) / Social Care Risk Assessment (SRA)
(secondary screening) process
Refer to Social Care team if A+B > 11, Refer to Health Care team if A+C >11
4.2 Community Delivery Team Meeting and Agenda Template
Core Attendees
GP representative/s, Community Matron, Community Matron (care homes),
District Nurses, Health Needs Advisor, Community Psychiatric Nurse, Social
Care link worker, Care Coordinator.
Purpose of the Meeting
The CDT meeting will take around 45mins to 1 hour discussion is a vital
component in the delivery of integrated care, providing information exchange,
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agreeing care pathways, roles and responsibilities and actions needed to ensure
comprehensive case management. Minutes to be taken by the Care Co-ordinator.
The Agenda
1. Feedback about Admissions & Discharges, Out of Hours (OOH) activity
and Falls recovery data: Care Co-ordinator & District Nurses (DN)
2. Case discussions : All
 Individuals identified by care coordinator using risk stratification
 Individuals identified by DN team where risk is increasing
 Individuals identified by Community Matron (CM) where risk is
decreasing
 Action planning/clarifying lead responsibility
 Review individuals from previous meeting discussions
3. General Information exchange - All
4. Problem solving/troubleshooting – All
5. Actions/information that needs to be escalated to CCG
6. AOB.
Following the meeting care coordinator will:
 Distribute minutes (post them on the practice network instead of sending
paper copies)
 Record decisions/action on individual care notes
 Complete referrals etc from action planning
 Amend risk database as appropriate (found in your ‘Care Coordinator’ folder
on your electronic system)
 Amend Falls prevention database as appropriate (also found in your ‘Care
Coordinator’ folder)
4.3 Guidelines for Care Co-ordinators making a call
Here are a few pointers when ringing hospitals/tracking individuals on the CDT
case list:
 Always have the information regarding the individual in from of you (Patient
data can be found on SystmOne; Social Care data can be found on
frameworki) as DOB/NHS/frameworki number, address, etc. are usually
requested)
 Introduce yourself as care-coordinator for the name of the practice you are
attached, explain that you work with the practice and would like an update
on the individual
 Try and find out:
o Diagnosis
o Current situation (improving/deteriorating)
o What treatment/ plans for rehabilitation
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o Any MDTs meetings/case conferences
o Discharge date
 Add a note to the individual record (journal)
 Admissions & Discharge Tracking Teams can be called upon to
assist/update discharge plans
 Social Work discharge teams should be contacted if individual has been
referred for social care assessment
4.4 Training/Induction Plan considerations for CDT team members
1. Practice systems - need to be familiar with patient record systems, document
management, message taking protocols, referral protocols etc.
2. Roles & responsibilities of wider practice - i.e. who does what: admin roles/
prescriptions / 'satellite' surgeries, DNs/ any 'specialist services (e.g. diabetic
/respiratory/physio etc), any voluntary support agencies, etc.
3. Protocols/Guidelines of role - need to establish working practice, i.e. working
with LTCs/over 65s/all patients? How decisions are made about
allocation/referral etc
4. Welfare rights/basic & form filling - helpful to understand the different benefits
available (DLA, attendance allowance, etc.) any referral for social care services
will result in benefits. Also helpful to be able to explain social care eligibility and
financial assessment requirement. If a social care worker is attached there will
probably not be a need for the Care Coordinator to complete BICCA, but again
will be helpful to know how to and what questions to ask.
5. Continuing Care criteria - understand criteria/know where to send
assessments/links to CC staff.
6. FACs - this is social care criteria, (see 4 above) need to understand this to
avoid inappropriate referrals and signpost people appropriately.
7.Important to understand that members of the team will have different
professional supervision needs and organisational policy and procedures from
their individual employers (e.g. DCHS/Social Care/Practice Manager etc), and
that this can sometime impact on the CDT. It is helpful if there is some
'joint' supervision arrangements agreed to assist with individual organisations
understanding and supporting the CDT process.
4.5. Protocols/guidelines to be developed by practice if not already in place
1. Practice message-taking protocol including standards to be met (from QOF
evidence)
2. Pathway for dealing with admissions and discharge information from
secondary care, communicating to relevant team member and risk
assessment arrangements to be undertaken
3. Pathway for referral into the case-managed register including self-referral
4. Operational definition of ‘frequent flyers’ and other criteria for inclusion in the
case-load
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5. Process and procedures for administration and documentation of care plans
including how they will be stored so all care givers can locate the information
they need.
6. Process and procedures for administration and documentation of end of life
pathway
7. Process and procedures for administration and documentation of individuals
on other case-managed pathways
8. Process and procedures for administration and documentation of palliative
care register
9. Process and procedures for creating reminders for individuals of monitoring
events/alerts and for harmonising case management with other practice
activities such as visits and consultations
10. Index/contact point for all relevant support agencies and information (to be
developed as one of first tasks of Care Co-ordinator)
11. System for acquiring views of individuals and carers on an on-going basis
including raising issues of unmet need and suggesting solutions
12. System for monitoring and evaluating the service
13. Standards for sharing good practice with colleague practices
14. Lone worker policy/insurance (if role undertaken in person’s home)
15. Policy/procedure for medication risk assessment (if included in role)
16. Policy/procedure for each clinical task to be undertaken (if included in role)
17. Induction and training plan
18. Terms of reference for weekly CDT meetings
4. 6 Reporting
4. 6.1 CDT Reporting Template
The aim of using a template are:
1. To reduce emergency admissions
2. To increase patient independence (in managing their conditions)
3. To reduce delays in getting appropriate support
4. To increase the number of patients with a case management support
5. To improve the patient experience
6. To provide cost effective care.
The template was designed as a way of holding care managed information and it
was expected that information gathered through input on the template would be
turned into reports to show if the aims were being met & provide ongoing
monitoring.
Activity/cost – provided by your reports from the cube (6)
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Community Delivery Team DAILY REPORT for the CARE COORDINATOR
Important Note
This reporting tool has been designed to provide a standardised approach of recording information daily about individuals in the Community Delivery
Team (CDT). It is the first draft and will evolve over the next month therefore we would appreciate your comments and feedback during the early weeks.
Please direct these to Julie Wilkinson on [email protected] or 07776 302543.
Instructions
This report is intended to report on 3 areas: 'active' CDT case list, current Acute Admissions and Discharges and current IC/Care/reablement
admissions. It will also hold a list of the discharged cases from the CDT for future reference (RIPs will be deleted)
The content of each is colour coded as follows:
Need to complete these sections
Need to use drop down boxes in these cells
Additional Information
Please note that this report is for daily monitoring. Other reporting will also include completing the 'CDT' template on Systmone which will provide
information for your practice(s), Erewash CCG, Derbyshire County Council and the Erewash Integrated Care Programme Board. If you have any queries
concerning the CDT template, please contact [email protected] or 01246 514990 or 07770 643206
Report view
In Acute Bed
Current Status
(for both Acute and IC/Respite/Care Home info)
Admitted
Discharged Hospital &
Reason for Current
dd/mm/yyy dd/mm/yyy Ward or Name admission Length of
y
y
of Home
(Diagnosis stay
)
In IC/Respite/ Care home/
reablement bed
On CDT case list
Admitted
Discharged
dd/mm/yyy dd/mm/yyyy
y
Admitted
Discharged
dd/mm/yyy dd/mm/yyyy
y
Continued Report View
when discharged, copy and paste from this column onwards onto next sheet
Name
DOB
NHS Number
dd/mm/yyyy
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No. of hospital Nomination
Risk
admits in last Criteria Score Score
12 months
To discuss
at CDT
mtg?
In CDT
case list?
On CC tel. Referral Source
call
register?
Case Manager
Case Manager Actions
Name
Progress Notes
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4. 6.2 SPA Reporting Template
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