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Community Services – Beyond Transfer to Transform Acute and Community Services “Integrators of Care” Linda Watson, Clinical Director of Community Services Carole Langrick, Deputy Chief Executive/Director of Strategic Development
Community Services – Beyond Transfer to Transform Presentation will cover: ,[object Object],[object Object],[object Object],[object Object]
Who are we? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Community Services – Beyond Transfer to Transform
Why did we do it? Community Services – Beyond Transfer to Transform
Community Services – Beyond Transfer to Transform What did we do? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Community Services – Beyond Transfer to Transform ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Transforming Services: End of Life Care
Community Services – Beyond Transfer to Transform Current State ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Service development Service development Service development Service development Clinical supervision Clinical supervision Community Macmillan Nurses x 2,  Macmillan Secretary x 1 (P/T)  Phoenix Centre Referrals Strategic meetings Consultant in Palliative Care x 1, Macmillan Nurse x 1  Secretary (P/T)  UHH Macmillan OT x 1,  Macmillan Physiotherapist x 1,  Palliative Care OT x 1  Hartlepool Hospice Education Audit Community Macmillan Nurse x 1  Masefield Road Community Macmillan Nurse x 1  Masefield Road Strategic meetings Strategic meetings Strategic meetings Strategic meetings Strategic meetings Referrals Referrals Referrals Referrals Referrals Referrals Audit Audit Audit Education Education Macmillan OT x 1,  Macmillan Physiotherapist x 1,  Macmillan OT Technician x 1  Lawson Street  Stockton Community Macmillan Nurse x 1,  Billingham Health Centre Consultant in Palliative Care x 1,  Nurse Consultant in Cancer and Palliative Care  Macmillan Nurse x 1  Secretary x 1 (P/T)  UHNT Community Macmillan Nurse x 1  Eaglescliffe Community Macmillan Nurse x 1,  Stockton Community Macmillan Social Worker x 1,  Billingham Council Offices Referrals Referrals Strategic meetings Strategic meetings Referrals Audit Audit Education Education Macmillan CNS Referrals Audit Referrals
Hartlepool   Consultant in Palliative Care x 1, Macmillan Nurse x 1  Secretary (P/T)  Community Macmillan Nurses x 3, Macmillan Nurse for care homes x 1  Macmillan OT x 1,  Macmillan Physiotherapist x 1,  Palliative Care OT x 1  Secretary x 1 (P/T) Strategic meetings Referrals Audit/Research Education North Tees   Consultant in Palliative Care x 1,  Nurse Consultant in Cancer and Palliative Care x 1  Macmillan Nurse x 1  Secretary x 1 (P/T)  Community Macmillan Nurse x 3,  Palliative Care Nurse for Care Homes x 1  Macmillan OT x 1,  Macmillan Physiotherapist x 1,  Macmillan OT Technician x 1  Community Macmillan Social Worker x 1,  Referrals Strategic meetings Referrals Education Referrals Service development Clinical supervision Audit/Research Education New SPC team structure
Service Delivery Expectations Community Services – Beyond Transfer to Transform ,[object Object],[object Object],[object Object],[object Object],[object Object]
Transforming services:  Intermediate Care and Reablement ,[object Object],[object Object],Community Services – Beyond Transfer to Transform
Intermediate Care and Reablement Current State Intermediate Care Rapid Response Community Stroke Falls Team OT’s Physiotherapy Assistants Reablement workers Rapid response Nurse HCA’s OTs Physiotherapy SLT Dietician Psychology Assistants Coordinator OT’s Physiotherapy Assistants Emergency Care Therapy and Acute Teams and RASWS Community Services – Beyond Transfer to Transform
Transforming Services:  MSK Services ,[object Object],[object Object],[object Object],[object Object],Community Services – Beyond Transfer to Transform
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Community Services – Beyond Transfer to Transform Transforming Services:  Community Virtual Ward
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Community Services – Beyond Transfer to Transform Anticipated Outcomes
Community Virtual Ward – Managed Care Pathway Managed Care Team (Single Point of Contact 24/7) Rapid Response, CM’S, DN’S, MDT, SOCIAL CARE (Primary Resources) GP Practices Acute Community  Medical Support IT   PCS Audit ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Outcomes; improved quality, patient satisfaction avoidance to hospital,  reduced admissions Patients identified using PARR ++  GP Practice to gain consent from patient to refer for Managed  Care Supporting Departments Intermediate Care Specialist Nursing Tele-health Pharmacy NEAS Secondary care services Business Support Departments Admin Training
Transforming Services:  Improved Quality ,[object Object],[object Object],[object Object],[object Object],Community Services – Beyond Transfer to Transform
Transforming Services:  Staff Experience ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Community Services – Beyond Transfer to Transform
Community Services – Beyond Transfer to Transform Thank you

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Transforming Community Services to Improve Patient Care

  • 1. Community Services – Beyond Transfer to Transform Acute and Community Services “Integrators of Care” Linda Watson, Clinical Director of Community Services Carole Langrick, Deputy Chief Executive/Director of Strategic Development
  • 2.
  • 3.
  • 4. Why did we do it? Community Services – Beyond Transfer to Transform
  • 5.
  • 6.
  • 7.
  • 8. Service development Service development Service development Service development Clinical supervision Clinical supervision Community Macmillan Nurses x 2, Macmillan Secretary x 1 (P/T) Phoenix Centre Referrals Strategic meetings Consultant in Palliative Care x 1, Macmillan Nurse x 1 Secretary (P/T) UHH Macmillan OT x 1, Macmillan Physiotherapist x 1, Palliative Care OT x 1 Hartlepool Hospice Education Audit Community Macmillan Nurse x 1 Masefield Road Community Macmillan Nurse x 1 Masefield Road Strategic meetings Strategic meetings Strategic meetings Strategic meetings Strategic meetings Referrals Referrals Referrals Referrals Referrals Referrals Audit Audit Audit Education Education Macmillan OT x 1, Macmillan Physiotherapist x 1, Macmillan OT Technician x 1 Lawson Street Stockton Community Macmillan Nurse x 1, Billingham Health Centre Consultant in Palliative Care x 1, Nurse Consultant in Cancer and Palliative Care Macmillan Nurse x 1 Secretary x 1 (P/T) UHNT Community Macmillan Nurse x 1 Eaglescliffe Community Macmillan Nurse x 1, Stockton Community Macmillan Social Worker x 1, Billingham Council Offices Referrals Referrals Strategic meetings Strategic meetings Referrals Audit Audit Education Education Macmillan CNS Referrals Audit Referrals
  • 9. Hartlepool Consultant in Palliative Care x 1, Macmillan Nurse x 1 Secretary (P/T) Community Macmillan Nurses x 3, Macmillan Nurse for care homes x 1 Macmillan OT x 1, Macmillan Physiotherapist x 1, Palliative Care OT x 1 Secretary x 1 (P/T) Strategic meetings Referrals Audit/Research Education North Tees Consultant in Palliative Care x 1, Nurse Consultant in Cancer and Palliative Care x 1 Macmillan Nurse x 1 Secretary x 1 (P/T) Community Macmillan Nurse x 3, Palliative Care Nurse for Care Homes x 1 Macmillan OT x 1, Macmillan Physiotherapist x 1, Macmillan OT Technician x 1 Community Macmillan Social Worker x 1, Referrals Strategic meetings Referrals Education Referrals Service development Clinical supervision Audit/Research Education New SPC team structure
  • 10.
  • 11.
  • 12. Intermediate Care and Reablement Current State Intermediate Care Rapid Response Community Stroke Falls Team OT’s Physiotherapy Assistants Reablement workers Rapid response Nurse HCA’s OTs Physiotherapy SLT Dietician Psychology Assistants Coordinator OT’s Physiotherapy Assistants Emergency Care Therapy and Acute Teams and RASWS Community Services – Beyond Transfer to Transform
  • 13.
  • 14.
  • 15.
  • 16.
  • 17.
  • 18.
  • 19. Community Services – Beyond Transfer to Transform Thank you

Hinweis der Redaktion

  1. North Tees and Hartlepool NHS Foundation Trust was established in December 2007 and provides healthcare services to a population of approximately 400,000 people in part of the North East of England. (slide with map). It covers an area from Easington in Durham in the North, Stockton in the South, Hartlepool in the East and parts of Sedgefield in Durham to the West. Service provision encompasses a wide range of health services covering some specialist acute services, a wide range of acute general hospital services, outreach services into community settings and, since 1 November 2008, the Foundation Trust has been hosting the full range of community services formerly provided by NHS Hartlepool and NHS Stockton-on-Tees. The organisation employs in excess of 5500 staff including the 800 in the hosted community services and has an income of c£230M.