Peter Wilde- Getting the most from a rapid response service
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CIS- community admission avoidance
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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