Case Study Submission
Date
Site
Contact Details
Title
6EA
(choose one, see AED)
8/6/16
NHS Forth Valley Community Services Directorate
Diane Sharp
Clinical Nurse Manager
[email protected]
Enhanced Community Team – Closer to Home
EA6: Ensuring Patients are Cared for in their Own Homes
Please describe the project in 250 Words
Aim
The Closer to Home: Enhanced Community Team model sits as part of a broader portfolio of
community development plans, for both health and social care, that provides support to individuals
to remain more resilient at home at a time of escalating need or ‘crisis’, 24 hours a day, 7 days a
week.
This dedicated additional capacity is based at a locality level to respond quickly providing enhanced
community service, primarily to avoid admission to acute hospital, but also facilitate timely hospital
discharge.
Anticipated Benefit [Description of anticipated benefit]
 A reduction in avoidable emergency hospital admissions and readmissions
 Additional capacity and resource within teams protected to deal with urgent community
demand.
 A more coordinated health and social care response to patient’s need particularly during times of
crisis
 More access to carer support during the day and overnight
 A better experience for patients
 More involvement of carers and support for carers at times of escalating need
Implementation & Approach [Improvement & Engagement approaches used]
The team have been employed with Joint Integration money to prevent avoidable hospital admission
and also provide support for those patients not quite clinically ready for discharge using a supported
‘step down’ model.
The team consists of;
- 1 Advanced Nurse Practitioner
- 6 Senior Staff Nurses, jointly funded by Falkirk/Stirling/Clacks Community Nursing. The
nursing part of the team are a stand-alone service- AHP resource, CPN resource
- Social work resource
- The AHP, CPN and Social work resource have increased existing services and managed within
existing teams.
They cover all 57 GP practices within Forth Valley. The service is for over 65s however those who are
under 65 and have a chronic condition i.e. MS, COPD, MND will also be considered.
The patients referred remain under the medical direction of their own GP.
There are 2 pathways which the teams are working with at the moment with a 3 rd pathway being
considered for later in 2016.
Pathway 1; Patients who have been seen by a medical practitioner and have a diagnosis made who
needs an enhanced service to prevent hospital admission in a crisis or deteriorating condition. ie
intensive nursing, AHP, CPN or social care package, equipment this can be one or all of these
services.
Pathway 2; Uninjured faller who in the main needs AHP input but may also need the other services.
The range of conditions can include chest infection, UTI, delirium, cellulitis. Falls but with no
suspected fracture. Acute exacerbation of chronic condition, reduced mobility due to acute illness.
Patients will be kept on the service for up to 7 days however if someone still needs input thereafter
for a few more days they would be kept on.
Outcome [Outcomes and evidence of impact of improvement on 6EAs, overall 4 hour performance
or specific flow group(s)]
Since implementation in December 2015, 331 patients have been admitted to the service primarily
preventing hospital admission however many of these patients were also to support discharge in a
timely manner.
Joint working and communication between all has demonstrated a good example of Case
Management and integrated working which has provided more appropriate care outcomes for the
patient. It has reduced duplication by using joint records and identifies the most appropriate service
to provide care. Anticipatory Care Plans are put in place prior to discharge from the service.
Key Lessons Learned
Providing 24h hour, 7 day cover has prevented avoidable hospital admissions; this has also facilitated
hospital discharges in individuals who would normally be admitted to hospital.
Working with the discharge hub daily has facilitated timely discharges thus reducing impact on
capacity.
Joint records have prevented duplication of information.
Working collaboratively with all services produces positive outcomes for individuals allowing them to
remain at home.
Your case study with considered for
presentation and publication in monthly
update. Please indicate if you do not agree.
☐
Return to: [email protected] by first Monday of every month
6 Essential Actions - Action Effect Diagram