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Integration – empowering people to stay at home

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Presentation given by Noreen Cushen-Brewster & Heather Howman of NHS Great Yarmouth and Waveney Integrated Care System at the Improving access to seven day services event. Crawley 11 March 2015.

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Integration – empowering people to stay at home

  1. 1. Integration – empowering people to stay at home NHS Great Yarmouth and Waveney Integrated Care System Noreen Cushen-Brewster & Heather Howman “Nothing between us that we cannot resolve.” 18/03/2015 1
  2. 2. 74,000 registrants with ECCH 18/03/2015 2
  3. 3. The Integrated Care System 18/03/2015 3
  4. 4. ADMISSIONS AVOIDANCE • Reduce unplanned care admissions • Keeping people out of hospital DISCHARGE • Early assessment • Timely • Care in right place • Avoid readmission UNPLANNED CARE • Early diagnosis • Right care, right place • Reduced length of stay One team One ICS One commitment One shared vision Seven Day Services PERSON Initial Key Focus Areas 18/03/2015 4
  5. 5. Patients told us it’s what they want – to stay at home It offers - • Better patient experience; retain independence • Recover faster & more fully • Improved dignity • Reduced exposure to communal acquired infections It helps the GY&W system - • Reduced number of emergency admissions • Reduced length of stay / timely discharge • Reduced reliance on long term care placements Patient, Family, Carer GP Independent Nurse Prescribers Senior Community Nurses & Therapists Social Work Practitioners & Assessors Rehabilitation & Re- ablement Practitioners Generic Workers Community Phlebotomists Day Coordinators (Health) & Duty Workers (Social) Administrators Why a 24/7 Out of Hospital Model? Beds with CARE Single Point of Access 18/03/2015 5
  6. 6. The Integrated Community Care Hub Kirkley Mill Campus, Lowestoft • Out of Hospital Team • GPs, in and out of hours • Therapists and Podiatrists • Community Nurses and Phlebotomists • Social Work Practitioners • Community Mental Health Practitioners • Pharmacists • Community Support Workers 18/03/2015 6
  7. 7. Lowestoft Out of Hospital Team; April to January 2014/15 “Making my life much easier than it would have been without their help” Out of Hospital Team Beds with Care Referral Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Total Total 51 56 69 64 70 71 116 116 121 108 310 Referral Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Total Total 6 3 1 6 7 6 8 8 8 11 64 18/03/2015 7
  8. 8. Lowestoft Out of Hospital Team; April to January 2014/15 “Able to provide better and quicker care” 0 5 10 15 20 25 30 35 40 45 50 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 18/03/2015 8
  9. 9. Case Study Before Patient known to have dementia Frequent dizzy spells Recurrent falls over 5 day period Wider family struggling to cope Joint assessment within 1 hour of referral, including full bloods After Appropriate equipment in the home Spouse able to assist with exercises Carers in place Wider family reassured of safety Mental Health Services informed 18/03/2015 9
  10. 10. Integration with Mental Health Teams: DIST Out of Hospital Team North Waveney Out of Hospital Team What’s next? 18/03/2015 10

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