Baseline Model of care for proposed community wards Appendix 1

Pyramid of care & care functions Components of Community wards Common referral processes Discharge

Care status and service response Acute condition Unstable long term condition or exacerbated episode Stable long term conditions or simple episodic care Self managing chronic condition Hospital Community Wards, including use of Independent Sector Nursing Homes Primary & Community services Self care with Local Health & Wellbeing resources Care statusCare function

Components of the Community Ward Locality Teams Shared Specialist community based teams Out of hours service Rapid access to agreed Hospital services/ Hospital out reach Core Community Wards Teams

R,R&R Community Matrons MHMH RehabRehab LTCLTC EoLEoL ELDERLyELDERLy Self Care Ward Team Admin Acute community Ward (HDU) Ward management/ Neighbourhood team GP Social Care Proposed Community Ward Model Acute Hosp.

RR&R named nurse linking directly with neighbourhood team named nurse, managing the most acutely unwell, then transferring into ward Ward admin leading on the admission and discharge process, linking with named nurses, GPs and community matrons Community matrons leading on the clinical support for the team, managing their caseload and the capacity of the service Community Ward Team Responsibilities

GP Clinical leadership for the ward/team, providing medical cover and support. Referring directly into team. Social Care Directly linked/named social care support, working closely with named nurses and community matrons Neighbourhood team to include therapies, and leads within specialist areas- End of Life, Mental health, long Term Conditions, Care of the Elderly and Rehab. Community Ward Team Responsibilities

Community Ward Core Teams Clinical team leader, ward clerk, community ward sisters, GPs, therapists, generic support workers, and social workers 7 core teams based within 4 existing localities with total capacity of c.280 patients at any one time Daily reporting on c.5 most ill patients Weekly reporting on c.35 patients Open 7am to 10pm for full service provision Clear discharge plan agreed at admission 7 days a week service with an out of hours service of 10 pm – 7am

Person known to current Locality Teams Criteria base assessment completed by professional (urgent or routine) Person not known to Locality Teams Single point of access called (protocols also agreed with Ambulance Service) Initial telephone triage Assessment requested (urgent or routine) Other support solutions identified Admission to hospital Primary/Community Locality Teams management) No further action required / appropriate signposting Admission to community ward and patient pathway commences Common referral process

Discharge Patient Discharge care/ intervention plan shared with patient and family Each patient will have goal driven plan and when achieved the patient can be discharged Planning Discharge/ transfer date set on admission Community Ward team will be the professionals who will plan the discharge via ‘ward round’ methodology Organisation Discharges can happen 7 days per week A Key Worker produces and signs off discharge and agreement on future reviews

Community Ward Out of Hours service 10pm to 7am Operational hours Urgent assessment and treatment Emergency assessment and referral for 999 Diagnostics Planned health care interventions Planned sitting service Low level reassurance to patients with LTC (and their carers) in their own homes. Services Carelink Carers Emergency Response service Links

Locality Teams & other local links 4 existing locality teams including community nurses, matrons, social workers and linkages with primary healthcare teams and community pharmacists Generic services, end of life care, wound dressings, continence, falls, dementia, IV’s, assessment and neuro. Linkages with primary care teams Linkages with community pharmacy 60 patients capacity (monthly review)

Rapid Response & Rehabilitation Community physiotherapy PodiatryTissue viabilityDietetics Speech & Language Therapy Musculoskeletal Specialist Diabetes Nursing Community Occupational Therapy Disabled Adult Resource Team Stroke Specialist Nurse Falls Prevention Gastrointestinal endoscopy Continence and Enuresis Community Hospital inpatient beds Community Pulmonary Specialist Community Services Services across 4 Localities and 7 Community Wards

Access to Hospital Services & Hospital out reach Diagnostics Specialist nurses/ Hot clinics/ Consultant advice

 Shared protocols.  Referral process.  Case Management.  Access to Equipment.  Long Term Care Database.  Transport into and out of A&E departments- reducing reliance on Ambulance Services.  Closer links with GP in A&E- RR&R nurses based alongside, timely Communication to prevent admission. Community Ward Enablers

 Close links with Out of Hours services and Ambulance services to prevent admissions.  7 day working for all professions.  Capacity management methodology to move resources to where it is required, based on the demand, to include out of hours community provision.  Telehealth to support those with chronic condition and prevent deterioration.  RiO in community service to improve communication between services – links required to GP, acute and Social Care systems.  Access to timely diagnostic results, allowing community clinicians to make swift decisions for the management of the person. Community Ward Enablers