Peter Wilde- Getting the most from a rapid response service
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This document summarizes community admission avoidance initiatives in an integrated borough. It describes the team, skills, outcomes, challenges, and future plans. The team uses two pathways - rapid response within 2 hours and rehabilitation within 24 hours - to avoid hospital admissions. The multidisciplinary team works to support patients in their homes and communities rather than admitting them to hospitals. Challenges include balancing short and long-term admission avoidance, team building, and competing priorities. The future plans focus on developing mental health services, quality improvement, staffing issues, and stakeholder engagement.
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iCares – population based delivery of care. Ruth Williams, Clinical Directorate Lead, Community and Therapies Clinical Group. Sandwell and West Birmingham Hospitals NHS Trust.
SIMTEGR8: Simulation To Evaluate Great Care
The document describes a simulation project called SIMTEGR8 that was conducted to evaluate the impact of interventions from the Better Care Fund on emergency admissions in Leicestershire, UK. The project used simulation modeling to assess four integrated care pathways and provide recommendations. Workshops were held with stakeholders and patients to discuss the pathways and identify issues. The findings from the project informed local commissioning of integrated care under the Better Care Fund.
community mental health.ppt
This document discusses community mental health, including its definition, shift from institutional to community care, settings, services, prevention strategies, and the nurse's role. Community mental health aims to help individuals live satisfactory lives within their communities through protective, curative, and rehabilitation measures. It represents mental health services provided in non-institutional settings like outpatient clinics, crisis centers, and day programs. The development of community mental health was in response to the realization that institutional care could encourage chronic illness rather than rehabilitation.
Tony woods and clare mahoney - Healthy Liverpool
Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning
Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London
Advancing Team-Based Care: Achieving Full Integration of Behavioral Health an...
This webinar highlighted ways to fully integrate behavioral health care into primary care. The role of nurses, medical assistants, behaviorists, lay health workers, and primary care providers was discussed along with the use of clinical dashboards and warm hand-offs.
This webinar was presented May 19, 2016 3:00 p.m. Eastern Time
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2.5 Partnership working - Anne Forletta, Katherine Hewitt
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Enhancing Efficiency and Best Outcomes in Community Care: CBI’s Transitional ...
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THE FRAMEWORK FOR SERVICE DELIVERY - GENERAL ADULT MENTAL HEALTH SERVICES
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Zeshan Ahmed Managing polypharmacy
This document provides information on polypharmacy and managing multiple medications. It defines appropriate and problematic polypharmacy. It discusses why polypharmacy is common in older patients living with multiple conditions. The document presents case studies of patients with polypharmacy and suggestions for optimizing their medications. It also provides resources for deprescribing and rationalizing polypharmacy when some medications may no longer be needed or beneficial.
Wendy Matthews Assessing capacity in an emergency
The document discusses assessing capacity and making decisions in a person's best interests according to the Mental Capacity Act 2005. It provides guidance on determining if a person has capacity, defining capacity, and considering someone's best interests if they lack capacity. Several case examples are also presented to demonstrate how to apply capacity assessments in different emergency healthcare scenarios.
Shuli Levy Continence
1) Continence problems are common in older adults and associated with increased morbidity, yet continence is often not considered a normal part of aging.
2) Common continence issues include urinary retention, urinary incontinence, and asymptomatic bacteriuria. Assessment involves history, examination, and sometimes tests.
3) Red flags that require further investigation include hematuria, acute kidney injury, recurrent infections, and symptoms of cord compression such as new incontinence or limb weakness. Management involves a multidisciplinary approach including specialists in urology, neurology, and geriatrics.
Sarah Brice Managing complexity in the acute environment
The document discusses managing complexity in the acute care environment for older patients. It outlines that a comprehensive geriatric assessment (CGA) is the gold standard for improving outcomes like hospital admissions, care home placement, and mortality. For patients presenting acutely, the document provides questions to guide assessment and decision making: determining if the patient is unwell, what care and support they need, and determining the best location for care between home with support, a step-up unit, or acute hospital. It also addresses assessing patient capacity for medical decisions.
Rachel Hames & Ian Kelso Advanced care planning 2
This document summarizes the work of a multi-disciplinary team based at North Kensington Medical Centre that implements advanced care planning initiatives for patients. The team consists of GPs, case managers, and health and social care assistants who work with over 5,000 patients, including 627 over age 65. Two key initiatives are My Care My Way, which provides integrated care through GP-led teams, and Message in a Bottle, which stores important medical information in patients' homes. The team aims to facilitate seamless care coordination and prevent unnecessary hospital admissions through anticipatory treatment plans that respect patients' wishes.
Nicola batrick trauma
1. Trauma in the elderly often results from falls rather than traffic collisions. Falls are commonly due to age-related factors like weakness, visual impairment, balance issues, or cognitive decline.
2. Trauma protocols should be modified for elderly patients, including lowering thresholds for imaging and considering falls from standing as criteria for trauma activation.
3. Evaluating and managing elderly trauma patients requires considering pre-existing conditions, medications, functional status, and risk of issues like delirium. Thorough evaluation and protocols help optimize care of the complex elderly trauma patient.
Mary Dawood Effective advocacy
The document discusses effective patient advocacy through two case studies and advice for nurses. In the first case study, a student nurse advocated for a patient by ensuring the consultant addressed the patient's care plan. In the second case study, a manager advocated for new flooring on a ward for older patients by presenting evidence of falls and complaints to the general manager. The document provides tips for nurses to build advocacy skills, such as identifying issues, developing requests supported by evidence, and raising awareness of their advocacy role with leaders.
Louise Hewitt functional assessment for all
Functional assessment involves evaluating a person's physical and cognitive ability to complete daily tasks. It is important for older adults as functional decline is common with age and conditions like chronic disease. Decline can lead to loss of independence and increased need for care. Assessments consider baseline function, individual needs, and aim to identify limitations in activities like mobility, personal care, and household chores. The results can guide interventions to compensate, restore, or educate to improve function and break the cycle of decline.
Louise butler Safeguarding adults
This document discusses adult safeguarding procedures and case studies. It outlines the four stages of the safeguarding process: concern/pre-referral, enquiry, safeguarding plan and review, and closing the enquiry. Case studies address issues like elder domestic abuse, pressure ulcers, do not attempt resuscitation (DNAR) orders, and families' role in decision making. It emphasizes obtaining consent, supporting patients' desires and best interests, considering capacity, and consulting families as part of the safeguarding and medical decision process. Future changes include emailing instead of faxing safeguarding forms to adult social care.
Liz rutherford NW london STP
The document introduces the Sustainability and Transformation Plan (STP) for North West London and the older people's care programme within it. It aims to share the programme's progress and priorities and seek feedback. The older people's care programme is focusing on getting health and social care systems to work together better for older adults, improving care for those in homes, supporting home-from-hospital care, end-of-life care, and commissioning high quality services. It has made achievements like establishing home as the preferred place of care and increasing rapid response services. The reference group aims to improve care coordination and address challenges like workforce development through its projects.
Katherine Buxton urgent end of life discussions
This document discusses priorities for end-of-life care of dying patients. It outlines 5 priorities: 1) recognizing that a patient is dying and communicating this, regularly reviewing decisions about care; 2) having sensitive communication between staff, patients, and families; 3) involving patients and their families in decisions about treatment; 4) listening to and respecting the needs of families; 5) providing individualized, compassionate care with an established care plan. It provides guidance on diagnosing dying, communication, shared decision-making, and developing a comprehensive plan of care.
Josh & Lucy communicating with a confused person in ed
The document provides tips for effectively communicating with confused patients in the emergency department (ED). It notes that patients may have barriers like word finding difficulties, reduced understanding, sensory issues, or reverting to their first language. The ED itself can also be confusing due barriers like noise, lights, activity levels, and unfamiliar faces. Some recommendations include speaking slowly, using simple sentences and repetition, being specific, offering choices, using visual cues, stating intentions, providing context, and keeping the patient oriented. Effective communication is important to help confused patients feel at ease in the fast-paced ED environment.
Jo james demetia vs delerium
This document defines dementia and delirium, differentiates between the two, and provides assessment and management tips for delirium. It notes that delirium is acute with sudden onset while dementia has slow onset and decline. Key points are that delirium is underrecognized, has poor outcomes if left untreated, and can be prevented and managed by addressing potential triggers and maintaining hydration, mobility, and nutrition. Assessment tools like CAM and 4AT can help identify delirium which requires prompt treatment of the underlying cause.
Jens Foell, Asssessing pain
This document discusses various topics related to pain assessment and management, including communication models, pharmacological and non-pharmacological interventions, and specific patient populations. It provides information on pharmacological properties and dosing of medications like duloxetine, venlafaxine, pregabalin, and gabapentin. Non-pharmacological approaches mentioned include self-management education programs and placebo effects. Specific populations discussed are the elderly, where start low and go slow principles apply due to changes in pharmacokinetics.
Gavin belson comprehensive geriatric assessment an introduction
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Comprehensive geriatric assessment (CGA) involves a multidisciplinary evaluation of an older person's medical conditions, mental health, functional ability, and social circumstances. The goal is to create a holistic care plan addressing treatment, rehabilitation, support, and long-term follow-up. A CGA benefits the patient through a coordinated care plan, benefits caregivers by addressing social needs, and benefits healthcare systems by reducing hospital readmissions.Caring for care homes self care bootcamp
This document discusses the importance of self-care and connection for older people in care homes. It outlines 5 ways to wellbeing: connecting, being active, taking notice, learning, and giving. Older people want to feel seen, involved, and connected to others. The document asks readers to share a "magic moment" of care and connection that reminds them why they work in care homes.
Caring for care homes bootcamp slides
This document outlines the aims and activities of the "Caring for Care Homes" program. The program aims to: 1) Build relationships amongst care home staff, 2) Improve skills for care workers, and 3) Enhance staff well-being. It does this through educational training programs, sharing best practices, and gathering feedback to improve care. The newsletter highlights success stories from care homes and interviews care workers. Upcoming events include training on dental care and reflection groups, as well as a "Share and Learn" event on building professional relationships amongst care home workers and staff.
Alison Lam Defining and measuring frailty
The document discusses defining and measuring frailty in older populations. It notes that frailty is a health condition related to aging where multiple body systems lose their ability to cope with stress. Frailty varies in severity and risk of adverse outcomes increases with higher frailty. Several screening tools are presented to help identify frailty based on deficits, symptoms, and functional abilities. Recognizing frailty is important so care plans can be tailored to prevent poor health outcomes in older vulnerable adults.
Adam backhouse, Viren Jeram, Clare thomson QI and frailty
This document summarizes the results of a diagnostic review of frailty services across two large hospitals conducted by a quality improvement team. The review found that only 1 in 5 frail acute patients received a comprehensive geriatric assessment (CGA). Audits showed that receiving a CGA reduced length of stay by an average of 2.5 days. The review identified opportunities to improve frailty identification, access to CGAs and specialist care, and reduce placement in inappropriate wards. The team outlined objectives to ensure all frail patients receive a CGA and specialist care as needed. Current and planned initiatives include expanding frailty teams, education, and standardizing the CGA process across both hospitals.
A patient journey
A patient's journey typically involves their carer contacting their GP who may dispatch rapid response or an ambulance provided by the London Ambulance Service to transport the patient to the hospital. However, the process is not always straightforward and linear, as it can involve interactions between the carer, GP, rapid response, ambulance, and hospital in varying orders depending on the specific needs and situation of the patient.
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Peter Wilde- Getting the most from a rapid response service
- 1. Community Admission Avoidance in Practice Lucy Allen Integrated Borough Lead H&F Community Independence Service
- 2. Plan • National perspective • Community admission avoidance • Hospital admission avoidance • Team • Skills • Outcomes • Challenges • Future
- 3. National perspective • Best patient care • Avoidable admissions • Frailty pathway • Integrated services • Case management / crisis resolution teams / intermediate care / telehealth / proactive management LTC • Efficient service delivery • https://youtu.be/l6iKZ_SOKCY
- 4. Frailty
- 5. Integrated Triborough Community Independence Service
- 6. Two Pathways Response within 2 hours when required. Treatment for 5 days Rapid Response Supporting people to: - get well after a physical illness - return home after hospital attendance - achieve specific rehabilitation goals with intervention from both health and social care. Response within 24 hours Commence treatment after 2 days of patient being ready for service* Progress goal(s) over 6 weeks Rehabilitation & Reablement SINGLE POINT OF REFERRAL CIS Liaison (formerly In-Reach) will also help hospitals identify patients who can be supported at home rather than admitted Services are provided between 8am – 8pm, 7 days a week. We cannot usually accept any rapid response referrals after 6pm.
- 8. Nurse Pharmacist GP / Geriatrician Physio Student Social worker HSCC Case manager Daily Red Bed MDT Occupational therapist Reablement
- 12. Skills • Problem solving / Creative thinking / Person centred • Range of competencies in addition to profession specific skills • Physical assessment / Signs of deteriorating patient / NEWS score • Long term condition management • Dementia and mental health awareness • Function / Equipment / Manual handling / Environment • Falls prevention • Goal setting and rehabilitation • Social support / networking / local knowledge • Psychological impact / motivation • Education & Promoting self management
- 14. Outcomes
- 16. Challenges • Short term / long term admission avoidance • Team building • Staff recruitment • Staff retention / training opportunities • Stakeholders feedback • Competing priorities • Partnership arrangement • Integrated service delivery • Short term commissioning
- 18. Future Resilience Develop mental health provision and joint working Service and quality improvement Staff recruitment and retention Performance reporting and commissioner feedback Stakeholder engagement Patient feedback and engagement
- 20. Resilience – 7 Factors • Emotional awareness and control • Impulse control • Realistic optimism • Self efficacy • Causal analysis • Empathy • Reaching out