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EREWASH INTEGRATED CARE FRAMEWORK 1. Population Needs 1.1 National/local context and evidence base It is acknowledged that in Erewash, access to community health and social care can be difficult and time consuming, requiring professionals to coordinate access to and input from multiple services and providers. This administration process does not represent an effective use of time. It is also acknowledged that population projections show an ageing population, such that by 2033 27.5% of the population will be aged over 65, 14.6% over 75 and 5.7% over 85. This ageing population will require more in terms of health and social care. In a survey in 2010/11 68.8% of people in England said they felt supported to manage their condition. However in Derbyshire only 53.9% said they felt supported, ranging from 50.8% in South Derbyshire to 57.3% in North East Derbyshire. This Integrated Care framework will introduce the systems and processes needed to support individuals with and without Long Term Conditions through seamless partnership working. (Source: Joint Strategic Needs Assessment 2012) 2. Scope 2.1 Aims and objectives of service 2.1.1 Aims The provision of supportive and enabling care closer to home has been the constant central theme of recent national health consultations and policies, to ultimately deliver better care for patients. To achieve high quality and cost-effective healthcare closer to home, a robust model of integrated care is required. The following study shows that integrated teams are a highly significant factor in improving care for people with long-term conditions: ‘Singh D. Transforming Chronic Care: Evidence about. Birmingham University (2005) meta-analysis’ This framework supports an Integrated Care Model which has been developed as part of the Erewash Integrated Care Programme. This is designed to provide an equitable needs-based service and continuity of care across a whole population. The aim is for all teams across health and social care to be integrated, sharing knowledge and skills and having respect for each other’s strengths so that it is as if it is one team delivering a service in equal partnership. The framework aims to deliver: A Single Point of Access Service An integrated Community Delivery Team service, with the teams working together and jointly agreeing how best to share work A common framework to ensure that individuals receive seamless care by accessing the right service at the right time, through strengthened Partnerships between Health and Social Care. This will be through the Integrated Care Model as described in Section 2.2.3. 2.1.2 Objectives The principles of the integrated care framework is to: Provide a co-ordinated service to receive ‘urgent/short term care’ and ‘longer term case management’ referrals from health and social care professionals within the community Establish and maintain a directory of services, detailing - where appropriate - daily capacity status, referral process to be followed, contact details and all other appropriate details as determined to support effective delivery of the service Facilitate and co-ordinate the provision of the care required to support the individual (health and social care) Monitor the delivery of care to ensure that the agreed health and social care input is received in a timely manner / to the timescales agreed Page 1 of 28 Improve accessibility to community services (health and social care) Decrease time spent by referrers navigating services in an urgent or longer term case situation Upon initiation of the agreed treatment plan/care, if the individual is assessed as requiring input from supporting services (see blue boxes in Section 2.2.3 (Model)), the service will facilitate the additional input required and provide feedback to the originating referrer. 2.1 Service description/care pathway 2.1.1. General Overview The integrated care service will be a single point of access to receive ‘urgent/short term care’ and ‘longer term case management’ referrals from health and social care professionals within the community. Urgent/short term care referrals will be routed into either ‘rapid response’ or ‘intermediate care team’ and longer term referrals will be directed to the Community Delivery Teams. 2.2.2 Service Description The different functions of the integrated care service includes: Single Point of Access Rapid Response Intermediate Care Team District Nursing Team (specific to Integrated Care) Community Delivery Teams. The individual specifications can be found in the Appendices section. 2.2.3 Service model Referrer t ee tm A no SP es for Do eria crit SPA Un pla nn ed Pl an Navigator ne Care Co-ordinator Routine Task Nomination Criteria Non Critical Rapid and Intermediate Response Care/Reablement YES Community Delivery Team DN team Nomination Criteria Score determines bias Health Critical <2hrs Referral Criteria Manage for required period Continual Assessment Secondary Screening Discharge/Refer Practice Acute Trust Appropriate for Case Management? Social Community Care Delivery Team Personalised Budgets Other - Case finding - Risk strat - MDT co-ord d Triage Manage for up to 6 weeks Role of CC Do for es n Ca ot m se Ma e e t c na rite ge ria me nt Social Care Colour code Decision point Tool/Criteria Services Supporting services For assessment YES NO NO Case Manager DN team Complex long-term If regular tasks management or required safeguarding Supporting NO Referrer Social Care Or signposting? Personalised Budgets Services Page 2 of 28 2.2.4 Care Pathways The service will support the provision of community services for the following care pathways: Rehabilitation and maintenance End of life care Urgent care services Falls (see also exclusion criteria section 2.4.3) 2.2.5 Days/Hours of operation SPA function - will be provided from 10am-6pm (accepting the last call/referral at 5pm) Monday to Friday. Rapid Response function- will be provided from 10am – 6.00pm Monday to Friday with the intention to move to 7 days per week. Intermediate Care function- will be provided from 8am – 6.00pm Monday to Friday with the intention to move to 7 days per week. District Nursing Team - the service operates 365 days of the year between 8.00 hrs and 18.30 hrs including weekends and bank holidays. The service is supported out of hours by the evening and night services. The hours of the three services will be continuous. Community Delivery Teams - will be provided from 9am – 5.00pm Monday to Friday. 2.2.6 Referral route Referrals will be received via a single dedicated telephone number. 2.2.7 Response time & detail and prioritisation The providers for each of the services must demonstrate the ability to match capacity with expected levels of demand, including predictable fluctuations. 2.2.8 Transfer of patient data The providers must establish and maintain clearly documented responsibilities and procedures in relation to the transfer of patient demographics and clinical information to receiving services in line with information governance standards. The service will provide to the referring community health care professional and the patients GP practice (if the referring community health care professional is not based in the GP practice), details of the outcome of the clinical navigation referral contact within 1 working day of the case closure. 2.3 Population covered It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the referral routes detailed in section 2.4.2. 2.4 Accessibility/acceptability 2.4.1 Accessibility/Acceptability • The Integrated Care Service will ensure that all individuals presenting with a health or social care need that can be appropriately & safely managed in the community are accepted for assessment and triage, as defined in the Model in section 2.2.3. • In addition case finding will focus on Long Term Conditions and Complex Case individuals selected by using a nomination criteria tool, secondary assessment and also a risk stratification tool. 2.4.2 Referral criteria and sources Referrals into the integrated care service will be accepted from the following professionals: General Practitioners Community Matrons Community Specialist Nurses* Advanced Nurse Practitioners* Practice Nurses* District Nurses* Page 3 of 28 Senior Practitioners (Adult Care) Emergency Care Practitioners Investigation of others including Emergency Department *following consultation with GP re patient condition and needs The provider will be responsible for the marketing and promotion of the service to the list of referrers as above. 2.4.3 Exclusion Criteria Individuals must be 18 years or over Individuals must be registered with an Erewash GP Individuals must have been assessed as not requiring acute hospital care (Category A patients) 2.5 Interdependencies with other services 2.5.1 Whole System Relationships The service will support effective flow across the health and social care system and reduce the number of nonelective admissions into an acute hospital which could be appropriately managed within a community setting. 2.5.2 Interdependencies • Social Care • Primary Care • Derbyshire Health United • Local hospice, palliative care team, care homes • East Midlands Ambulance Service • Patient Transport Service Providers • Derbyshire Hospitals NHS Foundation Trust • Nottingham University Hospital • Derbyshire Community Health Services (DCHS) • Medequip • Continuing Health Care • Derbyshire Health Foundation Trust • Erewash CVS with the local voluntary and community sector It is acknowledged that a key success factor of effective service delivery will be robust and productive working relationships between health and social care colleagues both at provider and commissioner levels. 2.5.3 Sub Contractors N/A 3. Applicable Service Standards 3.1 Applicable national standards eg NICE, Royal College NHS Outcomes Framework Domain 2: Enhancing quality of life for people with long term condition Domain 4: Ensuring people have a positive experience of care Right Care Recommendations for Derbyshire Cancer Chronic Obstructive Pulmonary Disease Cardio Vascular Disease QIPP Page 4 of 28 Long Term Conditions QIPP Workstream Programme CQC for care providers/homes Social Services standards** • Appropriate safeguarding arrangements • Integrated working with the NHS • Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention and early intervention • Universal information and advice services for all citizens • Proportionate social care assessments processes • Person centred planning and self-directed support to become mainstream activities with personal budgets which maximise choice and control • Mechanisms to involve family members and other carers • A framework which ensures people can exercise choice and control with advocacy and brokerage linked to the building of user-led organisations • Effective quality assurance and benchmarking arrangements (**Source: Derbyshire County Council Adult Service Plan 2010-2014) 3.2 Applicable local standards 3.2.1 The following dataset is required to be provided on a monthly basis Basic Inform ation Referral Inform ation Assessm ent Inform ation Outcom es Full Name Referred From Clinical Top to Toe (Y/N) Avoided Use of Services Pr actice New Patient (Y/N) Clinical Findings Attendance, Admission or Service Prov ided NHS Number Type of Contact (f2f, etc) Clinical Interventions Referred to and Accepted by iFramew ork PIN RISC Level Social Care Assessment (Y/N) Other Outcome (e.g. Refused Intervention) Initial Contact Date Pr imary Diagnosis Social Care Findings Early Discharge (Y/N) Gender Current Condition Ex acerbating Social Care Interventions Number of Bed Days Saved Age Number of LTCs Therapist Assessment (Y/N) Self Reported Change in Condition No. of Prescription Medications Therapist Findings Medication Issues Addressed No. of ‘Over the Counter’ Medications Therapist Interventions Recent Professional Attendance Medication Review Complete (Y/N) Medication Findings Medication Intervention 3.2.2 Service Audits The provider must undertake regular random sample audits. The reports are to be made available to commissioners. Examples may include: • Number of Right Care plans completed and shared across primary, secondary and social services • Significant event audit of people admitted to hospital who are being case managed • National Social Services measure: NI 135 – carers who have been assessed and in receipt of services • National Social Services measure: NI 136 – people supported to live independently through Social Services 4. Key Service Outcomes Page 5 of 28 • • • • • • • • • Reduction in average LOS of patients aged 65+ An increase in the number of people feeling supported to manage their own conditions A reduction in the number of falls experienced by older people Reduction in inappropriate unplanned admissions Increasing community-based treatment of Long Term Conditions Ensuring individuals have a positive experience of care Ongoing use of a Risk tool to continually monitor case list Reduction in the use of care homes Reduced overall costs of low level services 5. Location of Provider Premises SPA – based at Clay Cross Hospital Integrated Community Team South Erewash – based at Long Eaton Health Centre Integrated Community Team North Erewash – based at Ilkeston Community Hospital 6. Individual Service User Placement N/A Page 6 of 28 Appendix 1 NHS Standard Contract for Community Services Schedule 2 Part 1 Gateway Reference XXXX Service Single Point of Access Commissioner Lead Provider Lead Period 1. Scope 1.1 Aims and objectives of service The Single Point of Access (SPA) service will support individuals to receive appropriate care at home or as close as home as possible, and to prevent inappropriate hospital attendances and admissions through: Clinical Navigation Integrated Teams The SPA will accept referrals from the following Erewash CCG Senior Health Care Professionals: General Practitioners Community Matrons Advanced Nurse Practitioners* Practice Nurses* District Nurses* Community Specialist Nurses* Emergency Care Practitioners Investigation of others including Emergency Department These referrals will then be navigated to either the North or South Erewash Integrated Care Teams. The SPA ‘Navigator’ will take a full history from the referrer and complete the relevant documentation so that the referral can be patched out to the two Erewash teams with immediate effect. Examples of referrals may include Intermediate Care Beds, Packages of Care at Home, Occupational Therapy, Physiotherapy, Equipment. *following discussion with GP re patient condition and need 1.2 Service description/care pathway The service will be provided from 10am – 6pm accepting the last incoming call/referral at 5pm, allowing the Single Point of Access to complete the final calls of the day. This service will initially operate Monday to Friday. Existing services are available outside of these hours. The SPA will receive calls for access to community services, primarily from GPs and Community Matrons. All community/rehabilitation and re-ablement beds to be booked via the SPA. Direct bookings will not be taken. This will allow the current bed state to be managed and individuals to be prioritised by need. 1.3 Population covered It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the referral routes detailed in section 2.4.2 of the Integrated Care Framework. Page 7 of 28 1.4 Accessibility/acceptability 1.4.1 Accessibility/Acceptability Individuals over 18 years of age Care pathways may include for example: Frail Elderly – Falls Rehabilitation/maintenance – new difficulty with activities of daily living affecting ability to maintain independence at home resulting in risk of hospital admission Urgent Care – urinary retention, blocked catheter, acute infection End of Life – place of choice, anticipatory drugs 1.4.2 Exclusion Criteria Individuals under 18 years of age Individuals with an Acute Mental Health problem including alcohol and substance misuse Individuals with an acute dental problem Individuals with life threatening emergency health needs defined as Category A patients Individuals who require diagnostics i.e. X-Ray, Ultra-sound Individuals who are not registered with an Erewash GP Individuals who solely have social care needs. 1.5 Interdependencies with other services Derbyshire County Adult Care Derbyshire Health United Derby Hospitals NHS Trust Nottingham University Hospitals East Midlands Ambulance Services Derbyshire Healthcare NHS Foundation Trust 2. Applicable Service Standards 2.1 Applicable national standards eg NICE, Royal College NHS Outcomes Framework Domain 2: Enhancing quality of life for people with long term condition Domain 4: Ensuring people have a positive experience of care Right Care Recommendations for Derbyshire Cancer Chronic Obstructive Pulmonary Disease Cardio Vascular Disease QIPP Long Term Conditions QIPP Workstream Programme CQC for care providers/homes Social Services standards** • Appropriate safeguarding arrangements • Integrated working with the NHS • Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention and early intervention • Universal information and advice services for all citizens • Proportionate social care assessments processes Page 8 of 28 • • • • Person centred planning and self-directed support to become mainstream activities with personal budgets which maximise choice and control Mechanisms to involve family members and other carers A framework which ensures people can exercise choice and control with advocacy and brokerage linked to the building of user-led organisations Effective quality assurance and benchmarking arrangements (**Source: Derbyshire County Council Adult Service Plan 2010-2014) 2.2 Applicable local standards The SPA will be required to show the volume of activity coming through the service and to report back to Erewash CCG on a monthly basis. The Minimum Data Set required will be: Number of calls/referrals accepted Number of calls/referrals rejected Number of calls/referrals signposted to other services Nature of calls/referrals o Planned Long Term Case Management o Unplanned Critical (response required within 2 hours) Non critical (response required within the next 2 days) District Nursing Destination of calls/referrals (where this information is known) Source of calls/referrals 3. Key Service Outcomes The SPA is responsible for contributing to the delivery of the overarching outcomes as set out in the Integrated Care Framework. 5. Location of Provider Premises Clay Cross 6. Individual Service User Placement N/A Page 9 of 28 Appendix 2 NHS Standard Contract for Community Services Schedule 2 Part 1 Gateway Reference XXXX Service Rapid Response Function Commissioner Lead Erewash CCG Provider Lead DCHS Period April 2013 - 2014 1. Scope 1.1 Aims and objectives of service The focus of the Rapid Response Function is the prevention of potentially avoidable admissions to hospital services. The team will work in partnership with health care professionals and other agencies where assessment indicates that the patients’ immediate, individual needs can be met by the team in a timely and responsive manner. This may involve the option of multidisciplinary intervention if required and timely transfer to generic services. The Rapid Response function is available from within the community team, accessed via the SPA only and are for action the same day - when the individual is at risk of admission to hospital or care home. It includes: – Community Matrons on rotation – Therapists - now with extended working hours – Erewash Care team – Crisis Intervention 1.1 Aims To prevent, where possible, the potentially avoidable admission of patients to hospital services by providing support and therapeutic interventions during acute illness or sudden deterioration in condition. To ensure the speedy delivery of a high quality service that meets the needs of those, within the Erewash CCG registered GP population, at risk of a potentially avoidable hospital admission. To provide holistic assessment of need and necessary support, equipment and interventions to promote stability in the patients condition and enable them to remain in their own home. To work with partner professionals, agencies and organisation to enable the patient to be managed safely at home. To liaise and negotiate with other community based services to facilitate the transfer and continuity of high quality care. To address Erewash CCG and national priorities and targets whilst retaining a patient centred service. 1.2 Service description/care pathway The Rapid Response function is an Erewash CCG wide service available between the hours of 10.00 – 18.00, Monday to Friday with the intention to move to seven days a week. Varying levels of intervention are available in order to prevent avoidable hospital admission and incorporates: Rapid response and assessment. Crisis support. Support/intervention during acute illness. Page 10 of 28 The service is provided by a variety of disciplines, identified by patients need. Ensure holistic assessment and care planning. Provide timely interventions which focus on stabilising the acute situation and identifying on-going need. Facilitate timely and seamless transfer of care. Disciplines available: Community Matron Community Nurses Physiotherapist Occupational Therapist Support Workers Erewash Care Team Erewash care team work in partnership with Community 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 intervention 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. 1.3 Evidence Base Erewash CCG serves a registered population of 96,985. The vision is to improve the health, well being and quality of life of people in this area; by focusing on quality health and social care based on need which is provided in the right place, at the right time, by the right person with the right skills. The Government white paper “Our Health, Our say” – A new direction for community services’ (2004), proposed a significant change to the way Health and Social Care is delivered in the future, particularly through the development of capacity in primary care to deliver services historically provided by the hospital sector. 1.4 Population covered It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the referral routes detailed in section 2.4.2 of the Integrated Care Framework. 1.5 General Overview The service has recently been developed within the Integrated Care Pathway to refocus activity on the prevention of potentially avoidable hospital admissions. This element will proactively engage with key partners and providers within primary, community and secondary care to ensure timely support and interventions during the following each episode of care. This will involve response within four hours to community based referrals to the team and a smooth transfer to the intermediate care function or generic services as appropriate. 1.6 Accessibility/acceptability 1.6.1 Geographic Coverage / Boundaries The registered adult population of Erewash CCG. Excluded are citizens who are registered in Neighbouring CCG boundaries. . 1.6.2 Days / Hours of Operation The service will be operational between 10.00 to 18.00 hours (last referral accepted at 5.00pm), Monday to Friday with the intention to include seven day working during financial years 2013/14. 1.6.3 Response Time, Detail and Prioritisation A response time of 4 hours from receiving the referral is anticipated. All referrals will be assessed by Rapid Response Clinicians and the treatment / interventions will be planned and delivered in accordance to need. Page 11 of 28 1.6.4 Referral Criteria and Sources Any health and social care related professional referral source is accepted. Adults over the age of 18 years. Acute exacerbation or sudden deterioration in the patients’ condition in circumstances which leave them at risk of a potentially avoidable hospital admission. The patient must be registered with an Erewash GP practice as details in 1.4.1 above. 1.6.5 Referral Route Telephone referral via DCHS SPA. Information to support referrals can be faxed to the SPA. Contact number for any other communications via team landline. 1.6.6 Exclusion Criteria Those patients under 18 years of age. Those patients assessed as requiring hospital admission. Those patients requiring assessment by GP 1.7 Objectives To maximise the use of skilled clinicians to be benefit of patients during urgent/crisis episodes: To provide care closer to home. To prevent potentially avoidable hospital admissions To maximise the opportunity for patient choice regarding the location of care. – – – A health professional will visit within four hours in 100% of referrals accepted for assessment for Rapid Response. 100% of patients will be given 4 Harms Leaflet. 100% of patients will be screened for PU Risk. Improving Service Users Experience: – 100% of patients will be offered a service information leaflet. – 100% of patients will be offered a comment/complaint leaflet on admission to the service. – 100% of care plans will be formulated in collaboration with patients/carers. – Full explanation to patients/carers of any referrals made and the transfer of care arrangements will be evidenced in the patient records in 100% of episodes. 1.8 Interdependencies with other services 1.8.1 Whole System Relationships The Rapid Response function will be supported by the IC function and CDT to deliver a seamless services to safely support the individual: . 1.8.2 Interdependencies • Social Care • Primary Care • Derbyshire Health United • Local hospice, palliative care team, care homes • East Midlands Ambulance Service • Patient Transport Service Providers • Derbyshire Hospitals NHS Foundation Trust • Nottingham University Hospitals NHS Trust • Derbyshire Community Health Services (DCHS) teams • Medequip • British Red Cross • Continuing Health Care • Derbyshire Health Foundation Trust • Erewash CVS with the local voluntary and community sector • Specialist services eg tissue viability, heart failure, respiratory, diabetes, neurological and continence Page 12 of 28 teams 1.8.3 Sub Contractors No sub contractors are arranged for this service. 2. Applicable Service Standards 2.1 Applicable national standards e.g. NICE, Royal College NHS Outcomes Framework Domain 2: Enhancing quality of life for people with long term condition Domain 4: Ensuring people have a positive experience of care Right Care Recommendations for Derbyshire Cancer Chronic Obstructive Pulmonary Disease Cardio Vascular Disease QIPP Long Term Conditions QIPP Work stream Programme CQC for care providers/homes Social Services standards** • Appropriate safeguarding arrangements • Integrated working with the NHS • Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention and early intervention • Universal information and advice services for all citizens • Proportionate social care assessments processes • Person centred planning and self-directed support to become mainstream activities with personal budgets which maximise choice and control • Mechanisms to involve family members and other carers • A framework which ensures people can exercise choice and control with advocacy and brokerage linked to the building of user-led organisations • Effective quality assurance and benchmarking arrangements (**Source: Derbyshire County Council Adult Service Plan 2010-2014) 2.2 Applicable local standards 2.2.2 Service Audits 3. Key Service Outcomes The Rapid Response function is responsible for contributing to the delivery of the overarching outcomes as set out in the Integrated Care Framework. 3.1 Service Model The service strives to deliver a responsive service in keeping with Care Closer to Home principles combined with measurable high quality care in accordance with the domains that are set out in the Standards for Better Health Framework. 3.2 Care Pathways The team will respond to a referral within a four hour target. Assessment will take place and from the initial Page 13 of 28 contact an individualised plan will be formulated. The patient will access such pathways that are available in mainstream services. 3.3 Expected Outcomes To improve collaborative working across primary Care, Secondary Care, Voluntary and Independent Sector Organisations and Social Services. Reduce hospital admission. Reduce A&E attendance. Greater proportion of people supported to die in their preferred place of choice. Target response time of 4 hours will be achieved. 5. Location of Provider Premises Discharge Criteria and Planning Discharge planning will commence from the point of referral and form part of the assessment and care / intervention planning process. This will result in a smooth transfer to independence or generic services. (IC Function or Community Delivery Team). 6. Individual Service User Placement Self-Care and patient and Carer Information N/A Information leaflet to be developed providing details of the service in keeping with current policy on the production of patient information resources. 7. Quality and performance Standards Page 14 of 28 Appendix 3 NHS Standard Contract for Community Services Schedule 2 Part 1 Gateway Reference XXXX Service Intermediate Care Function Commissioner Lead Provider Lead Period 1. Scope 1.1 Aims and objectives of service Referrals will be received via the SPA. The aim of the Intermediate Care element of the integrated care pathway is to increase the health and wellbeing of the population of Erewash, by providing prompt assessment, treatment, advice and education to individuals in their own home who have experienced a recent deterioration in function or condition, and who may be at risk of admission or prolonged stay in acute or community hospital care, or residential care. A comprehensive assessment will result in a structured individual care plan that involves active therapy, treatment or opportunity for recovery, working closely with other health and social care professionals (e.g. social care staff, community nurses, community matrons and hospital-based staff), Interventions will normally be time limited up to a maximum of 6 weeks, (but will often be shorter) and which can be extended if the MDT can demonstrate the individual is making continued progress. 1.2 Service description/care pathway The Intermediate Care function aims to provide highly skilled multi disciplinary assessment and intervention to patients in their own home or current place of residence, with physical problems affecting their functional abilities. There is a patient-centred holistic approach, including comprehensive assessment and identification of problems. Goals are established in conjunction with patients and carers. There is on-going close liaison with other health and social care professionals to enable patients to achieve goals and maintain / achieve optimal independence. Close working with Derbyshire County Council Adult social care teams to ensure adequate provision of home support to enable patients to remain in their own home during their rehabilitation programme. Expected outcomes: Improve quality of future care Maximise and individuals functional ability and independence Timely transfer from acute or community hospital settings to facilitate on-going rehabilitation Prevent inappropriate / avoidable admission to acute or community hospital care Reduce or delay admission to long term residential care To reduce or minimise long term care packages Page 15 of 28 The service is currently available Mon – Fri 8am – 6pm with the intention to move to 7 days per week during 2013/14 Within intermediate care function is also the Erewash Falls service and Erewash care team: Erewash Care Team Erewash care team work in partnership with Community 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. 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 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 role 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 1.3 Population covered It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the referral routes detailed in section 2.4.2 of the Integrated Care Framework. 1.4 Accessibility/acceptability 1.4.1 Accessibility/Acceptability Individuals over 18 years of age and agreeable to receiving the service Recent deterioration in function At risk of hospital or residential care admissions or prolonged length of stay Individuals must be medically stable Requirement for intervention to have been assessed as being safely and effectively provide outside of an acute hospital, and within an individuals own home or current place of residence. Individuals motivated and able to undertake a rehabilitation programme 1.4.2 Referral criteria and sources Referrals will be accepted from the following: General Practitioners Acute hospital health and social care professionals Community specialist nurses Other members of the Integrated Care Teams Social care colleagues Practice nurses Page 16 of 28 1.4.3 Exclusion Criteria Individuals must be 18 years or over Individuals must be registered with an Erewash GP Individuals must have been assessed as not requiring acute hospital care. 1.5 Interdependencies with other services 1.5.1 Whole System Relationships The Intermediate Care function will support the rapid response function, as well as the community delivery teams and the community nursing team to deliver a seamless service to reduce the number of avoidable hospital admissions and reduce length of stay where an admission is required 1.5.2 Interdependencies • Social Care • Primary Care • Derbyshire Health United • Local hospice, palliative care team, care homes • East Midlands Ambulance Service • Patient Transport Service Providers • Derbyshire Hospitals NHS Foundation Trust • Nottingham University Hospitals NHS Trust • Derbyshire Community Health Services (DCHS) • Medequip • British Red Cross • Continuing Health Care • Derbyshire Health Foundation Trust • Erewash CVS with the local voluntary and community sector • Specialist services eg tissue viability, heart failure, respiratory, diabetes, neurological and continence teams 1.5.3 Sub Contractors N/A 2. Applicable Service Standards 2.1 Applicable national standards e.g. NICE, Royal College NHS Outcomes Framework Domain 2: Enhancing quality of life for people with long term condition Domain 4: Ensuring people have a positive experience of care Right Care Recommendations for Derbyshire Cancer Chronic Obstructive Pulmonary Disease Cardio Vascular Disease QIPP Long Term Conditions QIPP Work stream Programme CQC for care providers/homes Social Services standards** • Appropriate safeguarding arrangements • Integrated working with the NHS • Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention Page 17 of 28 • • • • • • and early intervention Universal information and advice services for all citizens Proportionate social care assessments processes Person centred planning and self-directed support to become mainstream activities with personal budgets which maximise choice and control Mechanisms to involve family members and other carers A framework which ensures people can exercise choice and control with advocacy and brokerage linked to the building of user-led organisations Effective quality assurance and benchmarking arrangements (**Source: Derbyshire County Council Adult Service Plan 2010-2014) 2.2 Applicable local standards 2.2.2 Service Audits 3. Key Service Outcomes The Integrated Care Team is responsible for contributing to the delivery of the overarching outcomes as set out in the Integrated Care Framework. 5. Location of Provider Premises Integrated Community Team North Erewash – based at Ilkeston Community Hospital Integrated Community Team South Erewash – based at Long Eaton Health Centre 6. Individual Service User Placement N/A Page 18 of 28 Appendix 4 NHS Standard Contract for Community Services Schedule 2 Part 1 Gateway Reference XXXX District Nursing (this is extracted from the ‘Community Nursing Contract Schedule) Service Commissioner Lead Provider Lead Period 1. Scope 1.1 Aims and objectives of service The Community Nursing service provides skilled, flexible nursing care to meet the needs of individuals and carers in the community. The service is delivered in a caring and non-judgmental 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. The principles of district nursing practice are to: Provide high quality, culturally sensitive nursing care for people in their own homes or community setting. Promote and maintain independent living. Enable patients to live independently by rehabilitation. Promote a co-ordinated approach to hospital discharge that facilitates a seamless service leading to improved health outcomes. Reduce the incidence of admission and re-admission by supporting and educating both patients and carers to seek early intervention for potentially debilitating conditions. Adopt a public health approach to clinical activities thus ensuring the most clinically effective use of resources to improve patient care. Promote user involvement in both service planning and delivery 1.2 Service description/care pathway The specification covers the roles of the district nursing team across 7 days a week. Patients suitable for a referral to Community Nursing services are those registered at the practice who require an out-of-surgery service performed by a suitably trained and skilled member of the community nurse team, so they are treated equitably with those who can attend surgery. The service will not be exclusively out-of-surgery as there will be circumstances where the specialist district nursing skills necessitate the service to be delivered in a clinic setting e.g. leg ulcer clinics. The service will include delivering care for people in residential care homes and care in nursing homes not usually expected of registered general nurses. Opportunistic support of those RGNs to develop their skills will also be undertaken as a routine part of caring for their patients. Page 19 of 28 Record Keeping There will be a system of record keeping integrated with the practice system so that care-givers and patients themselves can see a comprehensive record of activity within the record. It is expected that the improved system will eliminate duplication and improve the level of face to face contact time with patients. Training & Development The staff will be highly trained and professional. They will be valued and supported with access to continuing professional development provided by DCHS to enable professional progression. Work-placements will be provided for pre and post registration students as part of the agreement at cluster level with the provider to promote workforce recruitment and retention. The community nursing team will be practice-facing and take part in practice activities such as planning, clinical meetings, significant event meetings, regular case discussions, PBC meetings, and where appropriate to participate in in-house training including Quests and performance review. In some cases the teams will provide services on a locality basis where specialist skills are required, such as leg ulcer clinics. There will be regular face to face contact between the community nursing team and the GPs with a minimum expectation of a weekly contact. This is particularly important in practices where the district nurses are not based in the practice. The provider will develop a case management approach, integrating with the practice team to manage patients with long-term condition. These multi-skilled trained teams will have sufficient resource to meet need including for contingencies so that a core team will be available at all times. Arrangements for sickness and absence cover will be clearly defined with a clear process for resolving disputes. Each team will have administrative support in the style of a ward-clerk so that nursing time is maximised. Individual consortia will have the flexibility to create their own arrangements for accessing the District Nursing service and setting up lines of communication. Practices will have the opportunity to be involved in the recruitment of members of the DN team, and the appraisal process. As the Integrated Care model is rolled-out, the teams will integrate with social services according to the principles of the model. The following associated tasks that are considered to be core include: Advising residential homes on client care Specialist advice and guidance to Nursing Homes Safeguarding Vulnerable Adults Bowel Management Continence Management Catheter Management Ear Care End of Life – Terminal Care / Palliative Care Eye Care Hickman and PICC Line Management Leg Ulcer Management Medicine Administration Non medical prescribing Percutaneous Endoscopic Gastrostomy Tube Management Syringe Driver Management Page 20 of 28 Wound Care/Tissue Viability including complex wound management Phlebotomy Setting up or contributing to SAP personal held records The following additional tasks could also be included but would need to be negotiated by the joint team, with agreement within the team of who delivers which elements of the whole service. Chronic Disease Management (other than diabetes) including associated tasks i.e. spirometry, ECG, BPs, inhaler technique etc Flu and pneumonia vaccines Participation in an annual review of older people to include a multi-disciplinary assessment if required Medication review Health promotion The following core services requiring indirect intervention not listed above are: Ordering and requesting collection of equipment Greater use of assisted technology to maximise the potential for the patient to stay at home Nursing needs assessments for persons requiring a nursing home placement Telephone contact advice Planning effective discharge from hospital / hospice for patients with complex needs. Continuing care assessments Report writing for case conferences Documenting in GP practice patient records Specialist advice and guidance to nursing homes beyond the scope of a registered general nurse employed by the nursing home The above lists are not exhaustive and will change over time taking account changes in clinical practice and policy development. The service operates 365 days of the year between 8.00 hrs and 18.30 hrs including weekends and bank holidays. The service is supported out of hours by the evening and night services. The hours of the three services will be continuous. 1.3 Population covered The service will be provided for the patients registered with the practices within NHS Derbyshire. What about non registered patient emergencies e.g. older visitor from Europe…. 1.4 Accessibility/acceptability 1.4.1 Accessibility/Acceptability The service monitors acceptability through patient questionnaires. 1.4.2 Referral criteria and sources The assessment of whether a patient is judged to be in need of an ‘out of surgery’ service will be made by the integrated team and be based on wider interpretation of social and environmental factors. The team will reach agreement on treatment of patients discharged from hospital in need of follow up care within the context of flexible working and an integrated team approach. Referral route The referral process should be uncomplicated and auditable e.g. Emis tasks. The information to be provided is: Page 21 of 28 Patient’s name, address, date of birth, NHS number, telephone number, contact details, reason for referral, access details and the patient’s mobility status. Response time & detail and prioritisation When referring to the District Nursing service patients should be advised that the actual care and time that the nursing team will visit cannot be agreed until the District Nurse has received the referral details and assessed the patient’s need. All referrals to the service are prioritised and acted upon, the response time being dependant in the information received. High Risk- to be seen within 4 hours Patients in the community who require urgent nursing intervention (not medical), to prevent a potentially serious risk affecting the individual’s ability to stay at home. Medium Risk- telephone contact the same day and to be seen within 24 hours Nursing needs are clearly identified, actual risk of deterioration of patient’s condition if nursing intervention is not provided. Low Risk – telephone contact within 72 hours and visit within 7 days Nursing needs are clearly identified indicating potential deterioration without nursing intervention/monitoring. Minimal Risk- telephone contact within 72 hours and planned arranged visit arranged within 8 weeks To undertake a specialist needs led assessment/health screening where advice/support will maximise the continued independence of patient/carer. (Whereas continence assessments may be classed as minimal risk, the exception to this is faecal incontinence, where the underlying cause may be a nursing need, and should be classed with medium risk) 1.4.3 Exclusion Criteria 1.5 Interdependencies with other services 1.5.1 Whole System Relationships Community Nurses work in partnership with statutory, voluntary and private agencies to deliver continuing health care within the community setting. Patients are encouraged and assisted to maximise their level of independence and quality of life in the context of their own lifestyle with a view to being discharged from the Community Nursing caseload. 1.5.2 Interdependencies The key interdependencies are with the patient, carer, the Primary Health Care Team, Social Services, and Acute and Community Hospitals. 1.5.3 Sub Contractors 2. Applicable Service Standards 2.1 Applicable national standards e.g. NICE, Royal College 2.2 Applicable local standards Quality standards, outcome and performance management will be carried out at GP cluster level according to the matrix below. Page 22 of 28 The CCG expects the nurse management to be practice facing and to work with the practices to develop the teams, and to resolve outstanding issues relating to equity, record keeping, IT. Any changes to the level of service or the method of delivery will be negotiated with the practice and the cluster prior to the change being implemented. Wherever possible consideration should be given to skill mix and the introduction of administrative support. Practices will be given the opportunity to be fully involved in the recruitment process. Quarterly reviews will be held between GP clusters and DCHS locality managers to monitor and review performance and delivery against the quality standards as defined below and discuss proposed changes. Any issues that cannot be resolved within the quarterly review meeting will be escalated through the formal contract performance structure and discussed within the contract performance group. If a practice has significant concerns about the quality of the service delivered, these will be communicated to the appropriate DCHS manager outside of the formal review process and if appropriate raised formally through the contract management processes. The provider will implement appropriate national directives and best practice initiatives e.g. lean processes. The Provider delivering this service will be registered with the Care Quality Commission and compliant with the essential standards relating to quality and safety. 3. Key Service Outcomes An effective District Nursing team which is able to manage complex nursing intervention and packages of care within the skill mix of the teams, in patients’ own homes 5. Location of Provider Premises If the practice can provide adequate accommodation and appropriate working conditions, the District Nursing Team will be based in the practice. In cases where this is not possible, there will be regular meetings and communication links established to engender mutual respect and the development of shared goals. Where appropriate the District Nurses will provide care in a clinic setting to ensure that appropriate skills are utilised, such as tissue viability services. The practice will provide named links within the practice team, and have arrangements in place for induction of new members of the DN team. 6. Individual Service User Placement N/A Page 23 of 28 Appendix 5 NHS Standard Contract for Community Services Schedule 2 Part 1 Gateway Reference XXXX Service Community Delivery Teams Commissioner Lead Provider Lead Period 1. Scope 1.1 Aims and objectives of service 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 multidisciplinary 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. 1.2 Service description/care pathway General Practitioner 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 Page 24 of 28 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. 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 re-ablement 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 non-judgmental 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. 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. Page 25 of 28 1.3 Population covered It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the referral routes detailed in section 2.4.2 of the Integrated Care Framework. 1.4 Accessibility/acceptability 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 1.5 Interdependencies with other services 1.5.1 Whole System Relationships The CDT will support effective flow across the health and social care system and reduce the number of nonelective admissions into an acute hospital which could be appropriately managed within a community setting. 1.5.2 Interdependencies • Adult Social Care • Primary Care • Derbyshire Health United • Local hospice, palliative care team, care homes • East Midlands Ambulance Service • Patient Transport Service Providers • Derbyshire Hospitals NHS Foundation Trust • Nottingham University Hospital • Derbyshire Community Health Services (DCHS) • Continuing Health Care • Derbyshire Health Foundation Trust • Erewash CVS with the local voluntary and community sector It is acknowledged that a key success factor of effective service delivery will be robust and productive working relationships between health and social care colleagues. 1.5.3 Sub Contractors N/A 2. Applicable Service Standards 2.1 Applicable national standards eg NICE, Royal College NHS Outcomes Framework Domain 2: Enhancing quality of life for people with long term condition Domain 4: Ensuring people have a positive experience of care Right Care Recommendations for Derbyshire Cancer Chronic Obstructive Pulmonary Disease Cardio Vascular Disease QIPP Long Term Conditions QIPP Workstream Programme Page 26 of 28 CQC for care providers/homes Social Services standards** • Appropriate safeguarding arrangements • Integrated working with the NHS • Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention and early intervention • Universal information and advice services for all citizens • Proportionate social care assessments processes • Person centred planning and self-directed support to become mainstream activities with personal budgets which maximise choice and control • Mechanisms to involve family members and other carers • A framework which ensures people can exercise choice and control with advocacy and brokerage linked to the building of user-led organisations • Effective quality assurance and benchmarking arrangements (**Source: Derbyshire County Council Adult Service Plan 2010-2014) 2.2 Applicable local standards 2.2.2 Community Delivery Team report for Care Co-ordinators The Care Coordinator utilises a spread sheet to manage day to day activity within the CDT. It can be also used to gather and report on the following: Number of people who are on the CDT register, when admitted and who is case managing them Number of high risk individuals who are in hospital, length of stay, diagnosis, blocks in discharge process Number of individuals currently in a short stay, respite, rehab or reablement facility 3. Key Service Outcomes The Community Delivery Team is responsible for contributing to the delivery of the overarching outcomes as set out in the Integrated Care Framework. 5. Location of Provider Premises There will be six CDT’s that will work across the Erewash GP Practices. Please see Resource Plan* for detailed information. 6. Individual Service User Placement N/A Page 27 of 28 *Resource Plan – Community Delivery Teams Long Eaton Patch Ilkeston Patch TEAM 1 TEAM 2 TEAM 3 Total Population = 14,910 Total Population = 18,534 Total Population = 17,610 Adam House – 7,736 College Street – 7,174 Aitune – 9,478 Goldenbrook – 9,056 The Moir -14,485 Park View - 3,125 Community Delivery Team GP leads - tbc Care Coordinator – Farhana Chishti Community Matron – Jenny Garner 1 x AC Service Manager Community Delivery Team GP leads - tbc Care Coordinator – Caroline Hudson 1 x Community Matron (vacancy) 1 x AC Service Manager Community Delivery Team GP leads- tbc Care Coordinator – Marie Coates Community Matron – Dawn Brookes 1 x AC Service Manager Additional health 1 x band 6 5 x band 5 1 x band 3 Additional health 1 x band 6 7 x band 5 1 x band 3 Additional health 1 x band 6 5 x band 5 1 x band 3 Additional Adult Social Care Erewash wide team Additional Adult Social Care Erewash wide team Additional Adult Social Care Erewash wide team TEAM 4 TEAM 5 Total Population = 17,303 Total Population = 17,948 Old Station – 13,801 Eden Surgery – 3,502 Littlewick - 12,847 Gladstone House – 5,101 Dr Purnell & Partners – 3,855 Dr Webb & Partners – 3,889 Community Delivery Team GP leads - tbc Care Coordinator – Laura Ashby Community Matron – Sharon Vallis 1 x AC Service Manager Community Delivery Team GP leads - tbc Care Coordinator – Steph Elkin Community Matron – Gill Goodfellow 1 x AC Service Manager Community Delivery Team GP leads - tbc Care Coordinator – Angela Shaw (0.6) 0.6 x Community Matron (Sharon Vallis) 0.6 x AC Service Manager Additional health 1 x band 6 6 x band 5 1 x band 3 Additional health 1 x band 6 (30hrs) 6 x band 5 1 x band 3 Additional health 0.5 x band 6 2 x band 5 0.5 x band 3 Additional Adult Social Care Erewash wide team Additional Adult Social Care Erewash wide team Additional Adult Social Care Erewash wide team Telephone Numbers for Care Coordinators Team 1 Team 2 Team 3 Team 4 Team 5 Team 6 Farhana Chishti Caroline Hudson Marie Coates Laura Ashby Stephanie Elkins Angela Shaw 07827 346970 07827 346846 07827 354181 07827 349108 07827 354523 07827 355022 TEAM 6 DCHS (West Hallam Patch) Total Population = 9,293 Page 28 of 28 DCHS staff: Shared Team with West Hallam (SDCCG) West Hallam – 4987 Littlewick (WH pts) – 2,000* Health team Hours shared 0.5 x band 6 3 x band 5 0.5 x band 3 *The Community Matron in team 6 will manage the 2,000 Ilkeston Practice West Hallam pts