Allied Health within the Community Independence Service Hammersmith & Fulham Penny Magud & Gillian McTaggart 12th November2014

The Community Independence Service Is an Integrated Health & Social Care Crisis Response/Admission Avoidance Service within the community , 7 days per week The Service operates a ‘virtual ward’ model of case management & care coordination to avoid unnecessary institutional care Provides an In reach service into A & E/Medical Assessment Unit & the Older Persons Rapid Access Clinic (OPRAC) , as well as supporting earlier discharge & providing care to facilitate discharge Provides an integrated Intermediate Care/Therapy Led Reablement Service for up to 12 weeks Is the entry point for Health & Social care services

CIS service coordinator Community Independence Service Structure 1st November 2014 CIS service coordinator Assistant CIS coordinator 1 WTE Assistive Technology Coordinator 1 WTE Clinical nurse specialist, older age mental health. 2 WTE Physiotherapy Clinical lead 1WTE SPoR coordinator 1WTE Community Independence Assistants Team Leader 2 WTE Occupational Therapy Clinical Lead 1WTE Nurse clinical lead 1WTE Independent Living Assessment Team Lead 1WTE Physiotherapy Team 6 WTE Nursing team 6.2 WTE Admin team 7 WTE Assessor Group 10 WTE Community Independence Assistants 30 WTE OT team 7 WTE In-reach Team 6 WTE

The development of the Community Independence Service 3 Separate teams across Health & Social care to 1 integrated Health & Social Care Service Limited Allied Health Professionals in the services, 15 clinical Allied Health Staff within the team Care being provided under an enabling ethos, without Allied Health oversight or governance, to a multi professional, multi provider service managed by a Physiotherapist Unqualified assessing staff are now managed by an Allied Health Professional Health & Social Care senior leadership & oversight provided by 2 Occupational Therapists

Core Achievements Implementation of a Workforce Competency framework Development of a pre-registration to registered career pathway The development of the Hybrid Worker programme - up skilling of unqualified staff providing non-invasive nursing & therapeutic programmes - Multiskilled competencies developed for the Social Work, Nursing staff, Occupational Therapist’s & Physiotherapist ‘s within the service Increased complex patients supported in the community out of institutional care Increased patients whom have achieved their GOALS with the support of Therapeutic programme overseen by OT/Physio & under taken by CIA’s Setting up & managing the ‘Virtual Ward’, across multiple professions & multiple providers.

Virtual Ward team Adult Social Care Community Independence Service Patient Case Manager VW GP Health & Social Care Coordinator Community Independence Service Adult Social Care Other care providers community/ social/ voluntary Hospital Consultant Community Matron GP Practice

Outcomes Provision of in excess of 40,000 therapeutically delivered care hours last year for 1470 patients 45% of patients leave the CIS with no ongoing Health & Social Care needs Since April 2014, 508 ‘virtual ward’ patients have avoided an unnecessary hospital stay A further 468 people have been enabled to go straight home from A & E, avoiding unnecessary admission following a therapies assessment, review of their home situation & supported on the way home from Charing Cross Hospital 1000 bed days saved by providing a therapeutically lead in reach service enabling earlier supported discharge in 13/14