Download Integration – empowering people to stay at home

Integration – empowering
people to stay at home
NHS Great Yarmouth and
Waveney Integrated Care System
“Nothing between us that we cannot resolve.”
The Integrated Care System
Initial Key
Focus Areas
Seven Day
Services
ADMISSIONS AVOIDANCE
• Reduce unplanned care admissions
• Keeping people out of hospital
One
team
PERSON
One
commitment
DISCHARGE
•
•
•
•
Early assessment
Timely
Care in right place
Avoid readmission
One
shared
vision
One ICS
UNPLANNED
CARE
• Early diagnosis
• Right care, right place
• Reduced length of stay
Why a 24/7 Out of Hospital Model?
Patients told us it’s what they want – to stay at home
It offers • Better patient experience; retain independence
• Recover faster & more fully
• Improved dignity
• Reduced exposure to communal
acquired infections
•
•
•
Reduced number of emergency
admissions
Reduced length of stay /
timely discharge
Reduced reliance on long term
care placements
GP
Independent
Nurse
Prescribers
Administrators
Day
Coordinators
(Health) &
Duty Workers
(Social)
It helps the GY&W system -
Single Point of Access
Patient,
Family,
Carer
Social Work
Practitioners &
Assessors
Community
Phlebotomists
Beds
Generic
Workers
with
CARE
Senior
Community
Nurses &
Therapists
Rehabilitation
& Reablement
Practitioners
The Integrated Community Care Hub
Kirkley Mill Campus, Lowestoft
• Out of Hospital Team
• GPs, in and out of hours
• Therapists and Podiatrists
• Community Nurses and Phlebotomists
• Social Work Practitioners
• Community Mental Health Practitioners
• Pharmacists
• Community Support Workers
Lowestoft Out of Hospital Team; April to
August 2014
Out of Hospital Team
Referral
Total
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Total
51
56
69
64
70
310
Beds with Care
Referral
Total
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Total
5
5
1
5
3
19
“Making my life much easier than it would have been without their help”
Lowestoft Out of Hospital Team; April to August
2014
“Able to provide better and quicker care”
Lowestoft Out of Hospital Team
SUS Data – (April to July)
Emergency acute admissions Age 35 plus
Lowestoft
2013 - April to July
1868
Lowestoft
2014 - April to July
Variance
1700
Remainder of GY&W
2013 - April to July
Variance
-168
-8.99%
-151
-8.08%
-28
-0.93%
Remainder of GY&W
2014 - April to July
3006
2978
Changes in occupied bed days (April – July)
Emergency Admissions
2013 - April to July
2014 - April to July
14413
13751
-662
-4.59%
“It helped me walk quicker”
Case Study
Before
Patient known to have dementia
Frequent dizzy spells
Recurrent falls over 5 day period
Wider family struggling to cope
Joint assessment within 1 hour of referral,
including full bloods
After
Appropriate equipment in the home
Spouse able to assist with exercises
Medications review
Carers in place
Wider family reassured of safety
Mental Health Services informed