1. Older peoples services
Maximising rehabilitation, independence and flow

2. Community rehabilitation pathway: challenges
Oxfordshire is an outlier in terms of its bed base: how could we describe a community pathway which would allow the same level of rehabilitation and recovery within a smaller bed base, and provide ongoing care and interventions closer to home?
The patients who are now entering community hospitals have an increasingly acute presentation, complex care needs and less potential to recover previous levels of mobility, self-care and independence
Patients may do less well if they experience multiple handovers and transitions of care, unless close attention is paid to ensuring consistency of assessment, care planning and care delivery
Different methodologies do not appear to improve the success of predicting prior to admission which patients will and which patients will not significantly benefit from a community hospital stay
Staff delivering care in a bed-based setting may have different tolerance for and management of risk to their counterparts working in a community setting
In a system with a high number of delayed transfers of care and pressures on acute partners, how can we ensure we pay equal attention to admission avoidance (prevention of deterioration) as to supporting discharge and flow
How can we use the concept of care coordination or case management to improve care to frail older people?

3. Things that have made a difference
Integrated locality teams – district nursing, therapy, community mental health
Single point of access
Duty desks
Flow co-ordinators
Daily “flow” teleconference with partners
Weekly review of delayed patients
“Get me home week”
Mapping “as is” pathway as a system

4. What else we would like to do
Redesigning the rehabilitation pathway would offer a more personalised approach for individual patients with a focus on ensuring they receive appropriate care in an appropriate setting, flexing the pathway to meet individual needs.
We would:
Offer a rapid response to patients requiring MDT support to remain at home on a “virtual ward” model
Provide a standard discharge-to-assess function during the first few days of admission to a community hospital, to determine rehabilitation potential, agree a care plan and expedite discharge where individual patients will receive more benefit from an alternative care setting.
Review patient benefit every day using the red:green tool and agree early supported return home to continue the community rehabilitation pathway where this is indicated; or discharge home with a package of care; or onward transition to an alternative care setting where this is more appropriate.
Cohort patients to maximise skill mix; increase patient facing clinical time; improve patient outcomes and patient experience
Offer care coordination for patients with complex needs involving a number of teams or services

5. Supporting the transition home
We would offer a mixed model to take patients home with a case management or care coordination approach for patients with complex care needs:
The intention is to learn from the effectiveness of the older adult mental health model, where the community team maintains a virtual ward of all high risk patients being supported in the community, working collaboratively with the inpatient unit to support admission where required, and to ensure a timely and safe discharge back to the community team when the patient is ready.
Benefits are likely to include: patients receiving care closer to home; improved patient outcomes; reduction in ongoing care needs at the point of discharge; improved transitions of care; improved patient experience
Risks are likely to include: teams left holding people at home while awaiting ongoing care; compromised rapid response capacity; ability to predict patients who will be discharged with limited or no ongoing care needs

6. Older peoples services
Integrating community and primary care services

7. Exploring a Joint Enterprise
Oxfordshire GP Federations and OH Community Services
Brings together GP practices and community health services under single leadership
Neighbourhood (30-50k population), local delivery area ( k population) and county-wide clinical teams
Integration and enhanced MDT working where this is
Beneficial to the patient (joined up care)
Essential for sustainability (workforce skill mix)
Enables better efficiencies (back office functions)

8. To what purpose?
Ensure strong and stable GP and community health services for Oxfordshire
GP Operating Framework
Improve joined-up care for patients and carers
Five Year Forward View
Together with with hospital and social care partners, provide more care closer to home
Oxfordshire Transformation Plan

9. What will it look like in practice?
District nurses, community therapists, practice nurses and GPs working collaboratively to provide effective patient care at a neighbourhood level
Better coordination of physical and mental health interventions, integrated around the patient
Shared care planning
Shared management of patients at highest risk
Better use of resources
Improved patient outcomes (fewer and/or shorter admissions)