18 Community Transformation PDF 755 KB
Chris Holt, Chief Operating Officer, Rotherham Foundation Trust
Minutes:
Chris Holt, Chief Operating Officer, Rotherham Foundation Trust, gave the following presentation about Transforming Unscheduled Health Care:-
- Community Transformation launched in April 2014;
- Focus on five priorities
· A Better Community Nursing Service
Reconfigured around locality teams
Better leadership, clinical supervision and governance
Additional nurses (14 whole time equivalent posts) against the 2014/15 establishment
New ICT equipment, full connectivity
· Integrating Services in Health and Social Care (for issues such as falls, respiratory and neurological cases)
Developed new Integrated Rapid Response (merging Fast Response, Advanced Nurse Practitioners)
Respiratory Care Pathway agreed
Investment in Integrated Falls and Bone Health Care Pathway
New Service model for Neuro Rehabilitation
· An Enhanced Care Co-ordination Centre
Resourced to provide 24 hours’, s7 days per week cover
Hub for new supported Discharge and Admit Prevent Pathways
Develop single point of access for Community Nursing referrals
· Utilisation of alternative levels of care
Agreed model for Community Unit to target frail/elderly
Discharge to Assess beds commissioned at Waterside Grange
Three supported Discharge and Admission Prevention Pathways
· Better Governance and Performance Management
Performance Framework established across all Community Teams
Reporting mechanisms and indicators agreed with Teams
Bi-monthly meetings held between Clinical Commissioning Group and Community Teams
- ‘Input’ and milestone focus
- Secured successfully – need stage 2, as the initial programme had concluded in March 2015
- Acute was delivering but had struggled during the Winter
Current Situation – an Opportunity
- Provider of Acute and Community Services
- Community Transformation enablers
- A focus to improve within Acute
- Take a 2 to 3 year view
- Address other key enablers (Emergency Centre, 7/7 Services)
- Outcome and performance driven
Origins of the Programme
- Five Year Forward View
- Future Hospital Commission – Future hospital: caring for medical patients
A Future Model of Care
- Generalist Inpatient Pathways
The Medical Division: unified clinical, operational and financial management
7 days per week by trained doctors using Standard Operating Procedures
- Specialist Inpatient Pathways
Specialist procedures, clinics, ambulatory care and community support, specialist education, training and research
The Ambition
- Strengthened acute take and ambulatory care
- Ward reconfiguration and reduced bed base
- 7-day assessment of appropriate patients
- Community physician support for localities
- Reduction in acute length of stay
- Length of stay at home/Usual Point of Residence to be main indicators
- Primary, secondary and community partnerships
Five Key Priorities
- Emergency access and admissions
- Structured and systematic management of in-patient beds (acute and intermediate)
- Embedding Admission Prevention and Supported Discharge Pathways
- Integration of Acute and Community Care Pathways
- Partnerships with social care, mental health, voluntary sector partners
The presentation and subsequent discussion highlighted the following issues:-
: B1 Ward (at the Rotherham hospital) – reorganisation;
: the role of the Carats nurses (Community Assessment, Rehabilitation and Treatment Scheme); the multi-disciplinary team and the co-ordination of care; the multi-disciplinary teams review care plans daily for patients and telephone the Care Co-ordination Centre for advice and to arrange further care/support; ... view the full minutes text for item 18