Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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. 478172162 2 NHS Erewash Clinical Commissioning Group 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. 478172162 3 NHS Erewash Clinical Commissioning Group 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. 478172162 4 NHS Erewash Clinical Commissioning Group 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 478172162 5 NHS Erewash Clinical Commissioning Group 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. 478172162 6 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 NHS Erewash Clinical Commissioning Group 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 478172162 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 7 NHS Erewash Clinical Commissioning Group 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 _________________________ 478172162 Date___________ 8 NHS Erewash Clinical Commissioning Group 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, 478172162 9 NHS Erewash Clinical Commissioning Group 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 478172162 10 NHS Erewash Clinical Commissioning Group 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 478172162 11 NHS Erewash Clinical Commissioning Group 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) 478172162 12 NHS Erewash Clinical Commissioning Group 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 478172162 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 13 NHS Erewash Clinical Commissioning Group 4. 6.2 SPA Reporting Template 478172162 14 NHS Erewash Clinical Commissioning Group 478172162 15 NHS Erewash Clinical Commissioning Group 478172162 16