august 2019 care at the heart of our c mmunity
TRANSCRIPT
AUGUST 2019
If you would like to find out more or provide feedback on the programme please email [email protected]
Patient Story
Care at the heart of
OUR C MMUNITY
“ It is a very good service, the nurses help me and keep me in check. ”
Adam said:
The multi-disciplinary team approach adopted by the Rugby place based team is helping some of the community’s most complex patients receive first class care.
/nhsswftwww.swft.nhs.uk
A patient with a range of health and social care needs has benefitted from the collaboration between different organisations and professionals including South Warwickshire NHS Foundation Trust (SWFT) District and Specialist Palliative Care Nurses, Palliative Care Consultant and Substance Misuse Team, staff from Myton Hospice, GPs, Pharmacists, Connect Well, Age Concern and Macmillan.
In summer 2018, 41 year old Adam was referred to community services with palliative glioblastoma and a history of IV drug addiction. At this time Adam lived with his mother but had a desire to live in his own home. To help give Adam the independence he wanted, SWFT and Macmillan staff worked together to re-home him into his own flat. Here, Age Concern quickly fitted a key safe which gave nurses the ability to administer twice daily medication and the Trust’s Community Drugs Team supplied a lockable box.
iSPA and care co-ordinationA successful second pilot of care co-ordination has confirmed processes and provided good feedback to support the launch of the service at the end of September. The service will initially focus on urgent and same day referrals, to ensure a timely response can be provided for all patients.
Work is underway with West Midlands Ambulance Service (WMAS) to enable more community based responses to ambulance call outs as an alternative to a hospital conveyance when this is in the best interests of the patient. A two day pilot in July identified a number of patients who could be successfully supported to stay at home. A week long pilot with WMAS is being planned and if successful, a longer trial will take place over a month.
The next team to go live will be Warwick & Kenilworth. An engagement event for their Primary Care Network and other professionals is scheduled for 3 September. If you would like details of the event please contact Louise Hughes on [email protected]
3S E P T
P ace Based Teams
Weekly multi-disciplinary team meetings have now started in Camphill and Nuneaton Central. Any local professional can make a referral if they feel an individual would benefit from the support of a multidisciplinary team approach for their health and care needs.
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EXTENSIVE STAKEHOLDER ENGAGEMENT CONTINUED IN JULY FOR THE MODELS OF CARE.
A pilot of sharing out of hospital services data with GPs is due to go live in September. This will be done electronically through EMIS and will allow GPs to see details of the care their patients are receiving from out of hospital services in real time for the first time. Four Stratford practices are participating in the pilot. If successful, full implementation for all EMIS practices will follow over the subsequent months.
Initial scoping visits to all hospices have now been completed. The purpose of these was to identify their needs for an electronic patient record and to understand their current processes and record management systems. This first phase will help inform implementation planning and will provide a basis for further detailed work to be undertaken over the coming months.
Models of Care
TECHN010GY
The FRAILTY Model of Care was presented at the Falls system-wide workshop on 10 July and
the community teams were complimented on the excellent work they are doing.
The COPD Model of Care was presented at the STP Respiratory workshop on 12 July and it was agreed
that this would be adopted across the STP footprint. The components of ‘Living well with COPD’, Becoming
unwell with COPD’, ‘Really unwell with COPD’ and ‘Recovery’ provided the building blocks for systems working as each partner could identify which aspect
of the Model of Care they would contribute to.The Models of Care were SHARED with the North GP Forum on 18 July. They were well
received and the GPs were keen to understand who their key contacts were for joint working.
HEART FAILURE and COPD Models of Care were presented to North, Rugby and South
Working Together Boards. The feedback was very positive particularly around the specialist
consultant support offer for Primary Care Networks and Place Based Team working.
If you would like to provide any feedback on the Models of Care, please contact:
Rosie McDonnell, Head of Nursing