Integration of Community and Hospital Services

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Integration of Community and Hospital Services

• Phase 1 Transfer (completed March 2011)
• Phase 2 Transformation (2011 2013)

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Aims of Transformation

• To integrate community and acute services
• To improve the quality of care provided to
  patients
• To deliver the identified benefits

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Benefits to be delivered

• 1. Reduce steps in the patient pathway
• 2. Increase patient satisfaction
• 3. Reduce harm
• 4. Reduce operating costs
• 5. Increase community clinics
• 6. Reduce readmissions
• 7. Reduce management costs
• 8. Reduce length of stay
• 9. Reduce admissions
• 10. Reduce mortality

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• 16 Projects Grouped By Theme

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• New service
• Impacts on everyone
• Experiences to share
• Links to other projects

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Frail Elderly and Complex Care - Project Aim

• To improve the quality of care for frail
• elderly patients by
• Reducing inappropriate admissions
• Reducing readmissions
• Redirecting services to outreach into the
  community

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How do we define frail elderly?
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Project scope - Pathways

• Accident Emergency
• Hospital
• Intermediate Care
• Nursing / Residential Homes (1600 people)
• Peoples own homes

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Own Homes with support

• Health Service
• Social and Voluntary Care Services
• Charities
• Relatives.

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• More likely to become ill.
• Current services not geared up to support.
• Often admitted to Hospital.

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• Hospital can be the right place.
• Seen and looked after in own homes.
• Not unnecessary admitted to hospital.

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• New ways of working
• Specialist assessment and advice.
• Correct support.

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• Improve care
• Closer to / in home.
• Community staff.

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Frail Elderly Complex Care Project

• The Voluntary and Community Sector CAN help in
  the design of this new Service by giving the
  Trust your views and comments.

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• Gather your views
• Board of Directors
• Staff directly developing the new service.

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1. An Overview with questions.
2. A Questionnaire

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Keeping You Informed

• If you were looking after a frail elderly person.
  
• What information would be useful to you to help
  them?
• How would you like to receive this information?
• How would you like to be kept informed of the
  different types of help available for them?
• What would be important to support you as a
  carer?

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Developing The Service

• In developing this new service which of the
  following do you consider to be a priority?
• 24 hour / 7 day service
• Location
• Standard of Care

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Patients living in their own homes

• What do you consider to be a priority for them?
• Retaining independence
• Treated with dignity
• Involved in decisions about their care
• A named clinician with overall responsibility
• Outreach from the hospital
• Regular monitoring
• Links with other health and social care services

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Proposed Frail, Elderly and Complex Care Services

• Any Questions?