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Hull Intermediate Care Service Service Development Carol Crone / Jim Deacon May 2003 Team Information • Nurses ,Therapists,Social Care Staff • Referrals are from all health and social care departments • One main office base,one acute hospital base • Patients seen at home, also residential placements and nursing home beds • Team operates 24 hours/day 365 days/year Easing Bed Pressure • Red alert last winter • Acute and Community Managers want to work together to make a difference. (history of good relationship) • Immediate work required Transfer of Care Team • Intermediate Care Mini-Team @ hospital • Ward staff asked to complete a daily return of patients medically fit but for some reason could not leave the ward. Reasons for not leaving • • • • • • • Awaiting OT report Waiting for aids/adaptations Waiting for services to start Need observation A bit unsteady Need a blood test …….etc……. The Busy Ward • Staff looking after poorly patients • Complex access to Community Services • Initial reluctance re more forms to fill in (daily returns) I.C.Team • Daily returns to identify patients to “pull through” • Team able to focus on the discharge pathway .(not involved in other ward pressures) • Process may take time with some patients - others very quick I.C. Team (2) • Team aware of Community Services • Team able to directly access Int.Care immediately Dedicated Community Ward • Ward commissioned in Hull (in a nursing home) • GP responsible for ongoing care • Consultant from Acute Trust oversees • Nursing Care from nursing home • Part of IC Team -facilitates home follow up if further rehab. needed Team Commitment • Team flexible to meet need • Acute and Community see as one responsibility • Team in position to inform Commissioners Negatives • React to Crisis • Patients approached late (not part of admission and care pathway) • Several patient moves • Some clinicians not keen on patients leaving hospital system Positives • • • • • Patients had more choice Raised profile of I.Care in Acute setting Improved Communication “Revolving door” patients reduced Reduced trolley waits / Increased capacity • Reduced risk of hospital aquired infection The Future • This summer • Develop specific Care Pathways through the hospital • Consent document that addresses patient awareness re. rehab /nursing home placements etc The Future (2) • Improve sit reps. • Build upon current good relationships to Increase the team including Social Services • Simplify the discharge procedure straightforward community profiles Hull Intermediate Care Team Developing Services Carol Crone / Jim Deacon May 2003
