Community Hospital Review – The Clinical Model What did we recommend? Dr. David Carson, Director, The Primary Care Foundation

© Primary Care Foundation Opportunities in new integrated trust Draw on larger pool of expert community nurses Increase links to general practice and community staff Blur the boundary between the community and hospital care Potential economies of scale across the five hospitals

© Primary Care Foundation Good clinical practice Patients should not have delays waiting for decisions Evidence shows rapid senior decisions result in better outcomes: suggest daily ward rounds with medical and rehabilitation goals reviewed every morning (advanced nurse practitioner (ANP), and/or GP, and nurse and discharge coordinator present ) decision making at start of day Aim for consistent and regular expert clinical input Once per week is not adequate - ensure consultant ward rounds are twice a week and senior clinician – either Consultant or GP with a specialist interest (GPsi) leading the multidisciplinary team (MDT) Expertise needs to be maintained at weekends and out of hours – potential to increase therapy input at weekends to facilitate discharge

© Primary Care Foundation Principles … 1 Establish a common set of competencies across all units These should be sufficiently flexible to encompass local variation in admissions and case mix (GP direct admissions) Affordable Builds on existing strengths

© Primary Care Foundation Principles … 2 Builds on staffing resource in wider trust Allows a process of continual decision making and review Delivers baseline competency and expertise 24- hours every day Takes account of local availability of staff

© Primary Care Foundation Overall description of clinical model Consultant leadership and review twice weekly across all wards GP expert input to all wards daily Advanced Nurse Practitioner (ANP) cover all wards Monday to Friday Weekends, evenings and overnight ANP on call for all wards supported by medical on-call rota (Trust assumes full responsibility for cover out of hours)

© Primary Care Foundation Consultant role Overall responsibility At helm of early senior decision making – responsible for setting clear management plans and rehabilitation goals with the multi-disciplinary team (MDT) – they must be present at MDT Clinical leadership and mentoring – provide source of expert advice to all personnel especially ANP and GP Responsible jointly for length of stay and other key quality indicators with ward manager / part of clinical governance framework Twice weekly presence on the ward – maintained despite on- call commitments at acute hospital

© Primary Care Foundation GP role Expertise in care of older people Career development, training and mentoring Responsible for daily decision making and progress of rehabilitation assessment Build on existing expertise and roles across community hospitals Long term commitment from staff and trust

© Primary Care Foundation ANP role … 1 Daily presence to support care of patients starting with Board Round with other staff ( eg therapist / discharge co-ordinator ) at start of day Assessment and Prescribing ( we expect ANP to have core competencies – e.g. clinical assessment of patient; basic diagnosis-making, e.g. chest /urine infections; management of common scenarios, e.g. fever, hypoxia, hypotension, hypoglycaemia, confusion, GI bleed etc. ) Assessment on daily basis with decision making on daily basis

© Primary Care Foundation ANP role … 2 Progress actions, assessment, investigations and therapies so that goals are reached in expected time and problems identified early Ensure individual patients care plans are progressed. Ensure ANP is able to ask for senior advice at any time, so decisions are not delayed Ensure robust clinical governance system is in place

© Primary Care Foundation Implementation Commissioners used findings from our study to develop a specification in cooperative discussions with the trust Trust and commissioners now have the same goals Everyone underestimated the focus needed for implementation