learning disability services acute health / community ld team partnership working & service...
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Learning Disability ServicesAcute Health / Community LD Team
Partnership Working & Service Delivery
Tameside Hospital NHS Foundation Trust in conjunction with
Tameside Community LD Services
Making it work
Partnership
Joint working
Patient–Led services
Monitoring of Repeated attendances and readmissions• Flagging System• CLDT Admission list• Open Case information (nurse-held)• Patient Questionnaires• Easy-read-leaflets – desensitisation/ preventative
Next steps:• Tighten up data capture• Leaflet expansion
Individualised MDT Discharge Care Planning• Commence discharge planning on admission
• Hospital Passport
• Personalisation of care plans
• Admission Protocol, Flowchart & Referral processes
• Carers Care Plan – Carer Involvement
• Expected Date of Discharge within 24hours of admission at post-take Consultant Ward Rounds (Emergency admissions)
Individualised MDT Discharge Care Planning continued..• Handover process between Assessment area and Inpatients
• Individualised inpatient review of patient discharge care plan
• Individualised referral process - to appropriate MDT members/ Transfer Team - Social Care services
• Involvement of individual’s Community LDN
• Involvement of Hospital LDN if unknown to CLDT
• MDT Meetings – to plan/ activate discharge process
Patient & Carer Involvement in Discharge Planning• Meeting to suit the needs of the patient and carers
- On ward in first instance
- Flexible - can be held to suit need (i.e. elsewhere/ time)
• Use of Easy-read leaflets/ personalised information package
• Adaptation of follow-up treatment & appointments to suit need of individual
• Follow-up appointments – Easy-read letters, double appointment slots, location variation
Health Inequality Training All staff:• LD Awareness Training - Induction - all staff – raising awareness of
reasonable adjustments• Mandatory Training Workbook –linked to Safeguarding Adults to
maintain staff awareness
Clinical Staff:• Patient Focused Induction – for qualified & unqualified staff – held
quarterly • Adhoc training - formal and informal sessions delivered by LD Team
within both classroom and clinical settings
Further Development:
Interactive training sessions
User/ carer involvement to co-facilitate/ improve training package
The hospital liaison nurse will work in partnership with people with learning disabilities, their families / carers, and
other professionals, to provide a specialist service for people with learning disabilities
using hospital services
To ensure continuity of care following discharge
To ensure the recommendations from six
lives are implemented
To be the link person between hospital services and the community
learning disability team, to act a resource and point of contact for
acute trust staff
To use Person-centred approaches to facilitate and
support access to local acute services.
Collaborative working with colleagues in the acute trust
to ensure effective care planning and provision
To promote a positive image of people with LD
To lead on training and education sessions for acute trust staff in
LD awareness
Participate in local and regional support networks to ensure sharing
of current evidence and best
practice
Hospital Liaison Nurse Learning Disability
Hospital Liaison Nurse - Learning Disabilities
• Case Study – Older People’s General Medical Ward, TGH• Lady with Down’s Syndrome and Dementia. Admitted • due to seizures and diagnosed with Epilepsy.
– Initially had 1:1 support from community support workers. Ward staff joint worked with support workers when 2:1 support was required.
– Comprehensive handover when community support was withdrawn. Ensured there was a member of hospital staff on each shift who was aware of her additional needs.
– Additional Nursing Assistant on each shift to enable the 1:1 support to continue at key times
– Moved to a bed by the nurse’s station to facilitate increased observation
– Intro / desensitisation visit arranged to CT department. The patient was so relaxed during the visit that the Radiographer carried out the scan immediately even though it was his lunch break.
Moving Forward
Future Plans for Service Development
• Maintain actions from the Six Lives recommendations
• Actions identified from Acute Service Review
• Actions identified from Community Service Review
• Actions identified locally from patient/ carer feedback
• Actions/ Service review identified from complaints/ investigations
Sustainability
Partnership
Joint working
Patient - led service
Thank you…….any questions?
