BUSINESS CASE FOR IMPLEMENTATION OF HOME WARD
ACROSS LAMBETH AND SOUTHWARK PREPARED FOR THE ADMISSION AVOIDANCE PROGRAMME
BOARD 13TH June 2013
Submitted by:
Angela Dawe
Director of Operations, Community Services
Guy’s and St Thomas’ NHS Foundation Trust
Home Ward implementation
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CONTENTS
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5.1
5.2
5.3
5.4
5.5
5.6
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7.1
7.2
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Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
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Executive summary
Introduction
Background
Strategic objectives, benefits and scope of Home Ward
implementation
Home Ward service design
Overview and positioning
Location of Home Ward bases
Governance
Management structure, roles and functions
Education and training
IT and communications
Home Ward implementation – demand, capacity, occupancy
Financial case
Costing of Phase 1 implementation
Return on investment
Implementation plan
Communications plan
Risk analysis
Home Ward (GSTT@Home) Activity Analysis (WIP)
Home Ward (GSTT@Home) Implementation Plan
Home Ward (GSTT@Home) Communications Plan
Home Ward (GSTT@Home) Initial Risk Analysis
Home Ward Case studies
Equality and Equity Impact Assessment Initial Screening
Cost estimates for implementation of Home Ward
Overall impact of the Home Ward pharmacist
References and bibliography
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EXECUTIVE SUMMARY
The case for Home Ward
This proposal demonstrates a compelling case for implementing Home Ward
across Lambeth and Southwark and expanding the range of patients who can
access it.
The planned service will:
 provide safe, high quality, timely and tailored patient care at home that
would traditionally be provided in hospital;
 provide integrated services for complex patients, with a single point of
access;
 contribute to early identification of people likely to require an admission
and for whom, with dedicated health and social care, admission could be
avoided;
 provide for high quality and timely discharge, admission/readmission
avoidance and case finding of suitable patients identified in hospital;
 contribute to the development of new ACSC (ambulatory care sensitive
conditions) and other patient pathways;
 contribute to other GSTT (and KCH) work in transforming emergency
care;
 make significant financial savings in return for modest investment.
Fit for the future
The proposed implementation of Home Ward (HW) will make a major
contribution to the GSTT ‘Fit for the Future’ initiative (May 2013), which places
value at the centre of a drive to improve quality and safety whilst reducing
costs. The Home Ward service as designed is also integral to the planned
transformation of district nursing and the wider Community Health Services.
Patient choice
In addition to the high cost associated with hospital admission, prolonged length
of stay - especially in the frail elderly and those with long term conditions - can
lead to a higher risk of acquired infection and other complications, loss of
confidence, function and social networks. Increasingly, given the choice,
patients and their carers show a preference for receiving care at home, when
they have confidence that it will be provided by skilled practitioners offering
continuity of care and working collaboratively. Both Home Ward and Enhanced
Rapid Response (ERR) are integral to the work of the Older Peoples’ Pathway
developed by Southwark and Lambeth Integrated Care (SLIC) by providing rapid
support for people in their own homes.
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Quality and integration
It is clear from national evaluation of services similar to the planned Home Ward
(Munton et al 2011) that their effectiveness is influenced predominantly by the
quality of the services and their integration with other health and social services.
The Home Ward service planned has been designed for effective integration with
acute and primary care services, and with the wider Community and Social
Services.
A ‘City Model’ – complex, flexible, scalable
The planned service is a relatively complex model, encompassing admission
avoidance, early discharge and case management, though this is consistent with
a ‘City Model’ of virtual ward, and responds to the expectation of ever-growing
pressures on A&E, hospital beds, primary and social care. In view of the
complexity and scope of the development, the plans propose a new department
within Community Services, with four Home Wards encompassing nursing, social
work, GP, therapy and pharmacy (some of these roles are part-time) plus an
infrastructure which includes:
 a dedicated service management/clinical leadership role
 clinical practice development
 quality assurance, evaluation and research
 a clinical nurse practitioner in reaching into each hospital
 business support
 effective governance
ensuring flexibility and scalability of the service into the future.
A medium-term strategic development
In view of the strategic imperative for GSTT (Guys and St Thomas’ Trust) and
KCH (King’s College Hospital) to control costs and relieve acute pressures, the
new Home Ward department has been planned as a development that will
stabilise and grow over at least a five-year period. The planned service builds
capacity and systems which will allow the number of ‘virtual’ beds to increase in
response to demand (e.g. during winter) without additional major investment.
Building confidence and profile
Building confidence, profile, and ease of referral, for the new Home Ward service
will be key to its success, growth and cost effectiveness. A Communications
Plan has been developed to ensure that the service is effectively promoted,
understood and provides a mechanism for further feedback. In order to provide
the profile needed, both within GSTT/KHP and amongst partners and users, it is
proposed that the overall service be named “GSTT@Home”, subject to further
testing, with the ‘brand’. This is to enhance the visibility of the new service in
the community and to reflect the integrated nature of the Trust providing the
service.
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Quality of leadership
Many lessons have been learned from the Pilot Home Ward, and it is clear that
the step up to the planned service is significant, and the pace of managed
growth for the service challenging. The quality of the service leadership
appointment will be a critical success factor, as will recruitment and training of
the entire workforce, which will be conducted against clear person specifications
and a tailored Home Ward competency framework.
Role of support services
For an innovative, mobile, fast-moving community service, the development of
effective IT, electronic recording and telecommunications systems will be key.
In view of the importance of workforce, IT and estates services to the success,
quality and cost effectiveness of the Home Ward roll-out, it is envisaged that
dedicated one-stop liaison arrangements for each support service will need to be
established, with a shared accountability for the delivery of the new service to
schedule and to quality.
Capacity and demand
Activity analysis work that is currently being completed indicates that Home
Ward will be capable of supporting a wider range of conditions and interventions
than within the scope of the pilot. Initial projected demand for the established
service is about 4380 referrals per year, with a target length of stay of 5-7 days.
The plans allow for the following potential development phases:
 Phase 1.1 – 80 beds (4 wards x 20)
 Phase 1.2 – 100 beds (4 wards x 25)
 Phase 2 – 120 beds (4 wards x 30)
Demand estimates based on the limited usage of the Pilot phase indicate that
Phase 1.1 and 1.2 bed capacities are realistic.
Financial savings and return on investment
The costings for a service of this scale indicate potential maximum revenue
savings for Phase 1 of between £5.5m and £8m per annum, for 80%-100%
occupancy, compared to the current PbR tariff. Set against these potential
savings are capital costs for set-up of £487k (to be confirmed), which would
indicate a rapid payback for the capital investment.
Detailed comparative costs from other providers such as Medihome are not
available, but an out-of-town tariff suggests that the expanded Home Ward
service is likely to offer a more cost effective solution, in addition to the value
added which Home Ward offers from more integrated working across the Trust
and with Local Authorities, the more complex range of patients provided for, and
its wider impact in terms of the planned transformation of Community Services.
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Implementation planning
An outline implementation plan has been drawn up which emphasises the
challenge of becoming fully operational with Home Ward in time to ease winter
pressures in 2013. Plans for fast tracking stages of the development are
currently under consideration.
Conditions for success
Based on the evaluation of the Pilot, experience of services elsewhere and
stakeholder consultation, the following conditions for a successful HW expansion
are identified and incorporated into the service design and implementation
planning below:
1) Strong dedicated developmental and operational leadership, with effective
business support.
2) Stable recurrent funding to support a sustainable, rapidly developing,
service.
3) HW serving all GP practices in Lambeth and Southwark, who have regular
contact with representatives of the service.
4) An integrated IT and telecommunications system that is fit for purpose in
a mobile, rapid, geographically distributed service, including teleconferencing
capability for MDTs, and a business continuity plan to overcome any
interruption to critical IT information.
5) A scalable model of service delivery providing for a minimum 80 to 100
beds, sustaining occupancy levels that demonstrate cost effectiveness and
relief of pressure on in-patient beds.
6) Clear patient pathways for referral and expectations for length of stay in
Home Ward, with timescales for discharge regularly monitored.
7) A single point of access, with a streamlined and integrated referral
process for Home Ward and ERR, i.e. a single phone number and a single
route for e-referral, including ‘out of hours’ cover.
8) Excellent clinical nursing care combining best practice of acute and
community nursing, with confidence to treat more patients traditionally
cared for in acute settings.
9) Integrated multi-disciplinary and inter-disciplinary working, with clarity
about medical responsibility.
10) A consistent service presence in GST and KCH at the right level and
background, working with hospital teams, MDTs etc. This will be crucial to
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the visibility and effective take-up of Home Ward as an alternative to inpatient care.
11) Clear protocols for case managed patients, with Community Matrons
included in Home Ward multi-disciplinary team meetings.
12) Well-placed, appropriate office accommodation across the GSTT area, with
visible presence in the community (including nursing homes), primary care
and hospitals.
13) A ‘ready use’ equipment store, with a small number of key items e.g.
portable bladder scanner, home ADL and mobility equipment, IV stands, for
short term loan when existing equipment arrangements cannot meet service
needs.
14) A distinct, refreshed, dynamic @Home ‘identity’ for Home Ward and ERR,
supported by clear and professionally-designed communications/materials,
and consistent promotion to patients and referrers.
15) A new career pathway for community nursing, supported by tailored classleading HW training, to develop senior community practitioners with
advanced clinical reasoning, practice and decision-making skills.
Conclusion
There is a compelling strategic, clinical and financial case for the implementation
of Home Ward across Lambeth and Southwark. The development will need to be
effectively supported by related departments, and in particular by workforce, IT
and estates within support services. The Home Ward service planned is an
innovative and exciting development that will be central to the planned
transformation of Community Services. Wide consultation has taken place in
preparing this business case, which has achieved significant engagement across
the Trust, KHP (Kings Health Partnership) and primary care, to support the
expansion of Home Ward as described in this report.
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INTRODUCTION
2.1
This report sets out the business case and implementation plan for the
provision of Home Ward (HW) across Lambeth and Southwark – a
service which provides acute clinical care at home that would otherwise
be carried out in hospital. It also highlights a number of conditions for
successful implementation that will be met, including the relationship of
Home Ward to existing acute and community services.
2.2
A pilot service has been running since January 2012 in two locations
covering 25 GP practices (as at December 2012), serving approximately
30% of the total Lambeth and Southwark population. The pilot is one of
the initiatives supported by the Admission Avoidance Programme and
funded by reinvested readmissions monies.
2.3
The Home Ward pilot has worked in tandem with the Enhanced Rapid
Response (ERR) pilot, each service being under separate operational
management within the GSTT Community Services. The ERR service is
provided across both boroughs, making access for referrers
straightforward, whereas HW has been limited to GP practices registered
with the Pilot. The projects are overseen by a single operations group
reporting to Community SMT and the Admission Avoidance Programme
Board, comprising commissioners, GSTT, KCH and Social services
members.
2.4
The proposal to roll out Home Ward came from commissioners who
requested that a business case be developed which is affordable,
sustainable and makes a significant contribution to admission avoidance
and advanced discharge. Both Home Ward and ERR are integral to the
Older People’s Pathway developed by Southwark and Lambeth Integrated
Care (SLIC), by providing innovative rapid support for people in their
own homes. It was also envisaged that HW would provide a major
building block and agent for change in transforming community nursing
to meet future health care needs.
2.5
The HW pilot has been ambitious, combining what are often two distinct
services elsewhere – such as hospital at home/ambulatory care services
which focus on advanced discharge from hospital, or ‘virtual/community
wards which focus on identifying people for case management, through
predictive risk scoring with complex needs, usually arising from long
term conditions, who are most at risk of hospital admission. Their care is
then managed through enhanced and strong multi-disciplinary team
working.
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2.6
The GSTT Home Ward model supports early discharge by augmenting
secondary care, and can be provided at home within two hours of
referral, if required. It also increases the capacity of admission
avoidance in the community, through the speedy response of a nurseled multi-disciplinary team working in conjunction with GPs, Community
Matrons, District Nurses and the Rapid Response service. Through case
management, Home Ward works with GPs and Community Matrons to
respond to clinical needs or monitoring of people living in the community
with complex needs and who are at risk of hospital readmission.
2.7
The present report builds on a number of previous analyses and
evaluations of HW and related developments, notably:

an external evaluation of the Home Ward pilot and the Enhanced
Rapid Response schemes from Virginia Morley Associates
September 2012 including user feedback;

the original business case for the Home Ward Pilot as part of the
transformation of community services;

the new older people’s pathway developed by Southwark and
Lambeth Integrated Care (SLIC);

scoping work on the future of Home Ward in November 2012;

work on the Intermediate Care Pathway;

the current operational policy and medical model options papers;

patient and referrer feedback
2.8
This report incorporates the findings of a stakeholder consultation and
service observation during development of the business case. This work
elicited positive feedback and recommendations for further improvement
which have been incorporated in the plan. Those who had referred
patients to Home Ward - GPs, hospital Consultants, District Nurses etc expressed appreciation of the service and were keen that it should
continue and expand. They were eager for it to be available across both
boroughs. It is envisaged that further consultation will be undertaken to
refine details of the HW implementation plan.
2.9
The present report also draws on a review of other NHS and commercial
models of acute home-based provision including Medihome, Hospital at
Home Ltd, Orla, other NHS models and contact with virtual ward related
services in three other trusts in addition to Virtual Wards visited in the
original Pilot start-up and awareness of PACE (Post Acute Care
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Enablement Service) provided by Bromley Health Care (a social
enterprise).
 Wandsworth & St. George's Healthcare NHS Trust;
 University College London Hospitals Trust -including Community
Nursing Service – Camden;
 Barking, Havering and Redbridge NHS Hospitals Trust.
2.10
We are grateful for the openness and support of colleagues within GSTT,
King’s College Hospital (KCH), Primary Care, Social Services and across
Kings Health Partnership in formulating the present plans.
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3.
BACKGROUND
3.1
Lambeth and Southwark commissioners established an overarching
admission avoidance programme in 2011-12, focussed on developing
schemes to prevent hospital admissions and readmissions and to
enhance discharge. The programme has been governed by a joint
commissioner, provider and social care programme board (the Admission
Avoidance Programme Board).
3.2
Contract terms were agreed between commissioners, GSTT and Kings
College Hospital (KCH) to withhold funding for acute emergency
readmissions in line with the national guidance. A total of £5.3m was
agreed in 2011-12, which was used to support the Admission Avoidance
programme at a cost of £4.4m. This included the following initiatives:
 the Home Ward pilot, the focus of this business case;
 Enhanced Rapid Response;
 enhanced social work support;
 respiratory hospital at home;
 review of stroke readmissions;
 home equipment rapid access;
 handyperson service;
 discharge coordinator (Kings College Hospital);
 night owls (Southwark).
3.3
For 2012-13, national guidance in relation to emergency readmissions
changed, but it was agreed at the start of 2012-13 to roll forward 201112 funding assumptions and agreements in relation to emergency
readmissions, thus providing financial certainty for the year. The most
significant investment in the programme was for the Home Ward pilot
(£1.4m) and Enhanced Rapid Response (£2.1m) both of which were
commissioned from GSTT community services. Both schemes focus on
avoiding admissions and readmissions with a significant element agreed
to relate to the work of Southwark and Lambeth Integrated Care (SLIC).
The initiatives and funding for 2011-12 therefore supported both the
acute/commissioner contribution to SLIC plus also the wider whole
system admissions avoidance programme.
3.4
The Admission Avoidance Programme Board commissioned an external
evaluation of the Home Ward pilot and the Enhanced Rapid Response
schemes from Virginia Morley Associates to help inform the decisions
about the longer term roll out and mainstreaming of these initiatives.
The schemes were evaluated early, after six months of going live.
Conclusions included:
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Patient feedback about both services was overwhelmingly positive.
The two schemes experienced a number of initial teething problems,
but most had been overcome by the five month mark.
The full year cost for both schemes for 2012-13 is projected at
being between £3.3 and £3.4 million, against an allocation of £4.4
million. A preliminary internal analysis of costs at month five
suggests that the Home Ward scheme was no less costly than acute
care, but this reflected that the scheme had not been working at full
capacity (the pilot had suffered from a lack of GP endorsement and
a small catchment area), which pushed up bed costs and length of
stay.
3.5
In June 2012 the evaluators summarised the feedback and operational
problems that were highlighted during the qualitative interviews with
clinicians and others involved in the programme. This provided the
community services management team with an opportunity to resolve
outstanding problems where possible. In light of the above, it is evident
that the admission avoidance programme should be viewed as a
longer term strategic piece of work that is developed and
implemented over a 3 to 5 year period of time, aligned with the
integrated care programme. This will give the service a chance to learn
from the set up, improve any operational difficulties, provide an
opportunity to adjust and change referral patterns if required and for
more robust quantitative and qualitative evaluation to be completed as
part of larger externally commissioned evaluation of integrated care.
Lambeth and Southwark commissioners believe that the schemes that
have been funded can make inroads into acute pressures but that they
need to be given time to achieve this.
3.6
The Finance and Contracting leads from the commissioners and providers
met in the autumn of 2012 to review the funding assumptions with the
aim of securing firm funding commitments to enable both the SLIC and
the wider admissions avoidance programme to move forward and to
remove the annual funding uncertainty. In summary it was agreed that
acute providers were asked to commit in principle to funding the status
quo in relation to the wider admission avoidance schemes for 2013/14
and 2014/15, noting the funding expectation is to be confirmed by
commissioners, and that GST community services would work with
commissioners to develop as a priority a mutually acceptable business
case for the implementation of Home Ward. Further discussion would
then take place to agree funding sources to support this. In doing so,
links to wider systems issues such as Medihome contract and post
discharge tariffs need to be considered.
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3.7
Evaluation of admission avoidance initiatives across the UK have shown a
lower reduction in Accident and Emergency (A/E) attendances and
emergency admissions than anticipated. As a result greater emphasis is
being placed on evaluating outcomes and through ‘timely’ discharge, bed
days saved, increased patient satisfaction and readmissions prevention.
There is also a need for more research into factors and motivations that
influence both patients accessing and GPs referring to A/E.
3.8
The implementation of Home Ward will take place against a background
of considerable change. During this period, for example, Clinical
Commissioning Groups (CCGs) will be in operation, the implication of
changes to GPs contracts better understood, the community service
within GST better positioned, historical anomalies across the community
nursing service will be resolved, the role of Community Matrons will have
evolved, the full business case for King’s Health Partners Trust
completed, other integrated care initiatives including Community Multi
Disciplinary Teams (CMDTs) established, national guidance and research
about ‘virtual wards’ and similar developments will be more advanced,
and the evaluation of the GSTT’s Home Ward and ERR will have time to
yield meaningful data.
3.9
What will be constant is enormous pressure on secondary care, rising
demand in primary care, a changing patient case-load, financial
constraints and an increasing preference for patients to be cared for at
home (including care and residential homes) when circumstances permit.
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4.
STRATEGIC OBJECTIVES, BENEFITS AND SCOPE OF HOME WARD
4.1
Vision for Home Ward
The vision of Home Ward is to provide the best possible patient
experience and outcomes for all adults in Lambeth and Southwark
who can benefit from holistic, integrated, acute and intensive clinical
care at home.
4.2
Strategic objectives of Home Ward implementation
The strategic objectives of the implementation of Home Ward are:
a) To develop an innovative class-leading service that provides
integrated, acute, complex and intensive clinical care at home, with
optimum safeguarding for people who access this service.
b) To provide an equitable and responsive service on a scale that
meets local need, maximises service outcomes and improves the
patient experience.
c) To improve GSTT clinical outcomes and patient satisfaction.
d) To develop a service that gives confidence to GPs, hospital
consultants and other acute partners in referring, and confidence
to staff, patients and carers for timely discharge and admission
avoidance decisions.
e) To create a major building block, in the redesign of
community nursing and other community services. To increase
community nursing’s confidence in offering acute care and to upskill clinical staff in the community.
f)
To relieve pressure on acute services, reduce patient length of
stay, and facilitate better use of inpatient beds for elective and
other patients.
g) To support GSTT and KHP’s transformational objectives of improved
quality of care, improving efficiency and reducing cost.
h) These objectives will all be underpinned by the GSTT’s values and
behaviours framework to: put patients first; take pride in what we
do; strive to be the best; act with integrity.
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Integrated “at home” services with single point of access
To achieve the above objectives, via integrated multi-disciplinary
services, the fully implemented Home Ward, together with a fully
resourced and developed ERR will continue to work closely with GST and
KCH acute hospitals, with GPs, and District Nursing. Indeed, the Home
Ward pilot arrangements for working together will be strengthened and
formalised. The implementation plan will integrate all home-focused
interventions under the umbrella concept of GSTT @Home
(Kings@Home), as represented in Figure 1 below. This will include a
single point of access for all @Home services:
Improved Quality of Care and Patient Experience
Avoidance of Unnecessary Admissions
Figure 1
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Patient benefits from Home Ward implementation
Patient benefits from the fully implemented Home Ward are expected to
include:
a) decreased risk of acquired infections;
b) increased patient satisfaction;
c) reduction in disorientation/delirium (Shepperd 2009);
d) a lower risk of bowel or urinary complications (Caplan 1999);
e) a reduction in impact on functional ability (Caplan et al 2004; Leff
et al 2009);
f) overall the same or enhanced outcomes as hospital in-patient care;
g) reduced carer stress;
h) improvements in mortality (Cochrane review of Hospital at Home
Programmes finds improved mortality at six months from hospital
at home programmes that offer acute care in the homes of the
elderly (Shepperd et al 2008).
4.5
Hospitals’ benefits from Home Ward implementation
Hospital benefits from the fully implemented Home Ward are expected to
include:
a) improved patient flows to free up resources and support targets for
elective care;
b) a reduction in bed days utilised (through reducing avoidable;
admissions and readmissions and reducing length of hospital stay);
c) the ability to extend care options without major capital costs to
meet growing demand;
d) reducing patient process delays and improving information
exchange;
e) financial benefits through efficiency and HRG savings;
This model will also have wider implications beyond GSTT @ Home.
4.6
GPs’ benefits from Home Ward implementation
GPs’ benefits from the fully implemented Home Ward are expected to
include:
a) a rapid and responsive referral and discharge process as an
alternative to referral to A/E or regular hospital discharge;
b) information on progress during time with Home Ward and discharge
supplied more quickly;
c) a closer ongoing relationship between GPs and community nursing;
d) a reduction in GP input in acute interventions;
e) a reduction in demand on the community nursing service’s planned
workload during intensive acute home care.
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f) reducing patient process delays & improving information exchange.
4.7
Commissioners’ benefits from Home Ward implementation
Commissioner benefits from the fully implemented Home Ward Include:
a) a service which meets strategic and quality objectives;
b) potential financial savings from admission avoidance (see Section 7
and Table 10 below) and timely discharge;
c) support in meeting targets;
d) enhanced partnership working between NHS and Local Authority/
Social Services;
e) most importantly, improved patient outcomes.
4.8
Patient population covered by Home Ward implementation
The pilot HW service covers a GP-registered population of 207,201
(across 25 practices) out of a total population of 709,532 (figure taken
from the Exeter national database for Practice Populations – quarter 3
position). The objective is to develop capacity to meet the needs of the
whole population of Lambeth and Southwark, with the number of GP
surgeries involved rising from 25, at December 2012, to 99 GP surgeries.
4.9
Patient categories covered by Home Ward implementation
HW currently provides care for the following patient categories: early
discharge and admission avoidance for patients with a confirmed
diagnosis and defined care plan who require the following interventions –
intravenous therapy, subcutaneous hydration, general and blood
monitoring, cannulation and cannula care including peripherally inserted
enteral line and Hickman lines, anticoagulant therapy, complex wound
management including VAC (vacuum assisted closure) dressing, oxygen
therapy and nebulisers. Common conditions requiring these interventions
include: COPD (chronic obstructive pulmonary disease), cellulitis, heart
failure, urinary tract infection, pyelonephritis, asthma, chest infection
and pneumonia. Additional conditions and symptoms identified in the
March 13 audit included osteomyelitis, delirium, confusion, epilepsy.
(See also Section 6 and Appendix 1 below)
Detailed patient pathways relevant to Home Ward are being developed,
including additional ambulatory care sensitive (ACS) conditions that will
benefit from the service. Existing GSTT and KCH patient pathways will
be reviewed and physicians, geriatricians, specialist nurses, AHPs
(including specialist respiratory physiotherapists), Microbiology,
Pathology, and IPC (Infection Control and Prevention) will be fully
involved in the development of appropriate patient pathways and new
clinical protocols, through the Clinical Reference Group (see Fig 6).
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5.
HOME WARD SERVICE DESIGN
5.1
Overview and positioning
5.1.1
HW provides a new service offering medically prescribed acute clinical
care at home, which sits between traditional primary and secondary care
(Figure 2). It works in collaboration with services across the KHP and
Social Services to avoid duplication and promote continuity of care.
Figure 2 : Positioned between Hospital and Community
5.1.2
The long term objective of the implementation plan is to establish one
HW per locality. In Phase 1, 4 Wards will be established (North, South,
West and East) within a Trust-wide HW Department. The HW
Department will work in collaboration with the Enhanced Rapid Response
service, and will be integral to community nursing and GP practices. This
will be achieved through the establishment of two new additional Home
Wards, a presence in both hospitals and a dedicated service
manager/clinical lead:
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Figure 3 : Existing Pilot Home Wards
HW
Service
Manage
r
Figure 4 : Proposed Home Ward Department, with wards in 4 locations,
a presence in both hospitals and a dedicated Lead/service manager
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5.1.3
Each Home Ward will have 20-25 beds by the end of the Phase 1 rollout, giving an overall capacity of 80-100 HW beds. Each will
predominantly serve a ‘cluster’ of GP practices.
5.1.4
The establishment of a distinct Home Ward Department, with dedicated
leadership, is key to the effective and timely development of a complex
and innovative service. The new role of department Manager/Clinical
Lead will lead the development, in collaboration with a ‘Consultant
champion’, both in the implementation and evaluation of the roll out and
in the longer term development and maintenance of the cultural change
needed for Home Ward to reach its full potential.
5.1.5
The HW Department will have leadership, service development, service
promotion, business support, and quality monitoring responsibilities. It
will work to a 3-year business plan in line with SLIC timescales,
commissioning specifications and Trust strategic objectives.
5.1.6
The key purpose and ‘USP’ of the Home Ward Service is to provide
medically prescribed clinical treatments safely at home which would
otherwise require a hospital admission and are beyond the scope or
capacity of the current community nursing service.
5.1.7
Home Ward will be pivotal in shifting care safely to the community from
secondary care and limiting unnecessary admissions that can be
managed at home. It is essential that Home Ward has an identity which
reflects both the Trust’s community and acute functions and promotes
shared ownership along with primary care and Social Services.
5.1.8
HW will increasingly over time deal with more complex, new and higher
risk areas. Some of the patient pathways and treatments currently
undertaken by Home Ward may in future be carried out by the wider
Community Nursing service. This would follow a similar pattern to the
development of palliative care and other specialist services.
5.1.9
There will be opportunities to develop existing links with LSBU (London
Southbank University), KHP Clinical Academic Groups and other
academic institutions so that learning from research is used quickly,
consistently and systematically to improve the service and contributes to
education and training of the workforce for the future.
5.1.10 The Home Ward service thus has the potential to be a key building block
in the transformation of Community Nursing as it adapts to meet the
growing demands of primary and community care and to respond to the
ever-increasing pressures on secondary care. The timescales for the
implementation of Home Ward and work underway to transform
Community Nursing will be closely aligned.
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5.1.11 Working closely with other SLIC developments, Community Matrons and
ERR will enhance the HW service and increase its potential. The HW
implementation programme will ensure that the HW model is integrated
with the Enhanced Rapid Response provision within Therapy services and
other Admission Avoidance initiatives.
5.1.12 The Home Ward Department, with a robust infrastructure, service
leadership and developmental capacity, is designed to be scalable in
terms of:

the number of Home Ward locations across Southwark and Lambeth
– in Phase 1 there will be four, with a possible Phase 2 roll-out to
six, depending on demand, resources and manageability;

the capacity of Home Ward, ie the number of GP practices, the
number of beds within each ward, the total number of beds;

the range of patients seen through agreed pathways and
interventions;
to allow matching of service capacity with available resources, including
financial, HR support and available trained workforce.
5.1.13 Figure 5 below summarises referral routes to Home Ward and
relationships with other parts of the community and acute services and
professionals who will contribute to strong multi-disciplinary working.
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Figure 5 : Referrals to Home Ward and relationships with other
Adult Community Services
PRIMARY CARE
REFERRALS
GP-supported
Community Matrons
District Nurses, SS,
CMDTs, intermediate
care, Nursing Homes
etc
SECONDARY CARE
REFERRALS
Consultant-supported
Emergency Depts, EMU,
Acute
Physicians/Medicine
Geriatricians, other
Wards SS, Ambulance
Service etc
@Home
Services
Community Matrons
Home
Ward
District Nursing
Clinically-led
MDT
Community
ERR
Supportive Ambulance
Discharge
Reablement
Therapyled MDT
With SW
With SW
Locality Services
General Therapy
Services
SUPPORTING SERVICES
ICP, Microbiology, Pharmacy,
Pathology, Dietetics,
Mental Health, Spiritual Care,
CMDTs, Specialist AHPs incl COPD
physios, Specialist Nurses/Teams
(eg Palliative/EOL Care, Diabetes,
Respiratory, Tissue Viability) etc.
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5.1.13 In the longer term, the extension of the single point of access for the
@Home services to encompass all community nursing and therapy
services, together with an integrated recording system, is planned. The
aim is for integrated referral and recording systems that are easy to use,
responsive to lay users, ensure rapid professional clinical liaison, and
improve decision-making and service oversight. This development will
be taken forward in conjunction with SLIC work on simplified hospital
discharge.
5.2
Location of Home Ward bases
5.2.1
The location of the four Phase 1 HW North, South, East and West bases
will be selected to match the GP practices and populations covered and
optimise access to the principal Hospital with which each Ward is linked.
The HW Department base will be co-located with one of the HWs,
hospital bases or Community HQ - whichever will provide the best
strategic and developmental position.
5.2.2
Community services are best provided within a 15-20 minute travel time
and the @Home urgent service needs a short response time. This has
been used to identify the best locations, taking into account premises
and space available, and the Community Services premises utilisation
review. The requirements are being finalised and options considered as
a priority for decision will need to made by July 2013.
5.2.3
Hospital bases at GST and KCH will also be required
5.2.4
A detailed accommodation specification is being drawn up as part of the
implementation plan and will require lockable office accommodation,
storage, access to optimal IT, telecommunications, interview and
meeting rooms.
5.2.5
A transport specification will be developed as part of the implementation
plan to include time-saving and safe methods of transport for staff; use
public transport or drivers, pool cars versus owner drivers to match the
pattern of the service. Where possible, parking permits and parking
spaces for frequent user will need to be allocated at hospitals and other
bases.
5.3
Governance
Clear management and multi-disciplinary structures will be established
for the GSTT governance and oversight of Home Ward as part of the rollout implementation, to support and integrate the @Home services and
ensure Trust-wide engagement and confidence:
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Figure 6 : GSTT governance structure for
@Home services and Home Ward
Commissioners
ramme ramme+
Southwark &
Lambeth
Integrated Care
GSTT TME
Community
Directorate
Consultants – A/E, EMU
Microbiology, Pathology
Acute Medicine
Elderly Care
CNSs
Special PAMS etc
At Home
Steering Group
(Home Ward and ERR)
At Home
Management Group
(Home Ward and ERR)
Matron
Matron
Home Ward
North
Home Ward
East
Nursing and
MD Teams
Nursing and
MD Teams
Matron
Matron
Home Ward
South
Home Ward
West
Nursing and
MD Teams
Nursing and
MD Teams
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Clinical
Reference Group
Consultants - A/E, EMU
Microbiology, Pathology
Acute Medicine
Elderly Care
CNSs
Special AHPs etc
Clinical
Nurse
Practitioner
GSTT Acute
Clinical Teams
Clinical
Nurse
Practitioner
Kings Acute
Clinical Teams
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5.4
Management structure, roles and functions
5.4.1
Operational line management of the four Home Ward Matrons who lead
the multidisciplinary teams, and two Clinical Nurse Practitioners liaising
with acute colleagues and case finding in the hospitals, will be to the new
role of Home Ward Department Service Manger/Clinical lead. This
dedicated Home Ward leadership and development role will report to the
Head of Community Nursing and Nursing Practice:
Figure 7 : GSTT @ Home Professional Leadership Group
Head of Community Nursing
and Nursing Practice
@ Home
Business Support,
Service Admin’
Coordination
istration
Matron
Home Ward North
Service Manager/
Clinical Lead
Clinical Nurse
Practitioner
GP Lead*
Acute
Matron
GSTT
Clinical Practice
Development
Lead
Therapy Lead
Home Ward South
Matron
Home Ward East
Clinical Nurse
Practitioner
Pharmacy Lead*
Acute
Matron
Home Ward West
Kings
Social Work
Lead
Manage and
supervise
Work closely
with hospitals:
Professional
Leads
Nursing and MDT
teams
- Case finding
- Fast track tests
- Clinical liaison
North/South/
East/West
*lead in rotation
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West
Quality
Assurance,
Evaluation and
Research
Lead
Practice
Development
functions
working closely
with IPC team
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Within each Home Ward, the workforce and structure will be as follows:
Figure 8 : Structure and workforce of each Home Ward
At Home
Service Manager/
Clinical Lead
Home Ward
Matron
Ward Clerk
Nursing Team
Band 6s
Social
Worker*
(0.5 WTE)
GP*
(0.5 WTE)
Physio/
Occupational
Therapist*
Pharmacist*
(0.5 WTE)
Band 5s
HCAs
* will have professional accountability clearly identified
5.4.3
Home Ward will require integrated multi-disciplinary and interdisciplinary working, with clarity about medical responsibility:
The Home Ward GP will generally hold delegated responsibility for the
duration of a Home Ward stay on behalf of the patient’s GP, transfer to
Home Ward being counted as a ‘discharge’
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There may be an elective discharge pathway, ie patients whose elective
hospital care is shortened, with the consultant retaining responsibility.
This requires further consideration.
In Phase 1 implementation there will be greater involvement of
Consultant physicians, Geriatricians, Infection Prevention and Control
and from SLAM (South London and Maudsley NHS Trust) in MDT
meetings as well as on the Clinical Reference Group.
5.4.4
GPs
The right level of dedicated GP input to Home Ward is crucial, and not
always included in costings of comparative models. The proposal that GP
cover will now be 09.00hrs to 18.30hrs is currently being negotiated by
commissioners with LMC, an extension to the Pilot arrangement, with out
of hours cover currently provided by Seldoc. One whole time equivalent
has covered two wards and a corresponding increase in this
establishment for four wards is included in the budget. This will be
provided through the most cost effective contractual arrangement.
5.4.5
Pharmacist
Pharmacist input to the Home Ward team has also proved crucial (a
particular feature of GSTT’s service) both for patient care outcomes and
for staff training. The plan provides for 0.25 WTE per ward cross service
cover will best be provided by 2 0.5 WTE posts.
5.4.6
Nurses
Grade 6 nurses are included per ward and will be able to act as team
leaders providing professional mentoring and progression opportunities
for Grade 5 nurses and developing HCAs.
The nursing workforce model is based on bed numbers, level of
dependency and length of stay over a 7-day service with a response time
of 2 hours if necessary. The nursing and therapy teams will be working in
an integrated and interdependent way and this will be recognised in the
training and development plan for staff. Consideration is being given to
the best way of piloting 24hr on-call for GSTT @ Home and building on
the Night Owls pilot in Southwark.
5.4.7
Ward Matrons
Two additional new Home Ward Matrons will be appointed, with
consideration being given to the posts being developmental with support
where relevant from experienced Matrons and the new Service
Manager/Clinical Lead.
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Hospital-based Clinical Nurse Practitioners
The aim of the two new hospital-based in-reach roles is to encourage
timely and appropriate referral; case finding by being visible and working
with A/E and EMU (Emergency Medical Unit) and other colleagues,
attending MDT and readmission meetings; helping to safely extend the
boundaries of potential acute and complex care in the community;
reviewing processes that delay discharge home or to Home Ward and
increasing confidence of secondary care staff in the work of Home Ward.
Being based in the hospital will give prompt access to patient records,
investigations and results, and assist with staff’s induction, training and
rotation within the hospital. It is envisaged that these roles will primarily
cover late morning to early evening (eg 11.00hrs to 18.30hrs) initially
Monday to Friday with cover funded for shorter hours at the weekend, to
be reviewed. It will be important to ensure good relationships with
existing discharge teams, respect boundaries and avoid any possible
duplication.
A detailed specification of this pivotal new function is being developed in
conjunction with key HW and hospital-based colleagues. With these
roles in place, the community-based HW Matrons will be able to focus on
promoting the service to the surgeries and community nursing teams in
their ‘patch’ and developing the team whilst having hospital input when
covering annual leave and study leave, providing cross-Trust liaison and
influencing potential.
5.4.9
Therapists
The therapies workforce is designed to cover a 7-day service, with a lead
therapist and ward-allocated therapists. The Lead Therapist will be
responsible for development, management and coordination of the
therapy team’s input as well case work, reporting to the service manager
and be clinically supervised within ERR. They will line manage Band 6s,
coordinate cover for HW staff, lead practice and staff development
including skills sharing with HW nurses, social worker etc. In addition
they will provide capacity in ERR to help meet and manage all HW needs
not aligned with assigned therapists.
One therapist (physiotherapist or occupational therapist) will be colocated Monday to Friday as part of the HW team. They will be line
managed and professionally supervised by the Lead Therapist and report
to the HW Matron for day-to-day operation and service delivery. They
will undertake assessments and short/urgent treatment, sign post and
facilitate access to other therapy services and cover other ERR needs
where capacity allows. Where appropriate all HW patients needing
ongoing rehabilitation or treatment will be seen by the ERR Team, which
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will also flex to meet all therapy needs for the patient where the
allocated therapist does not have capacity to meet all needs within the
timeframe required. All weekend needs will be covered by ERR weekend
team.
5.4.10 Social Workers
A Social Worker (0.5WTE) will be co-located Monday to Friday as part of
each HW team. They will be operationally managed by the HW Matron on
a day-to-day basis and professionally supervised by a dedicated Senior
SW Practitioner who will usually also supervise Social Workers attached
to ERR. They will undertake assessments and short/urgent care, signpost, teach HW colleagues, facilitate access to other social services
(including voluntary agencies), liaise with patients’ known Social Workers
and ensure OOH arrangements are disseminated and understood by
other members of the HW team.
5.4.11 Permanent posts
It is proposed that at least 80% of the HW team are permanent
members (and long-term secondment) with scope for community nursing
staff and acute nursing and therapy staff rotating into the service.
5.4.12 Workforce costing
Costings for the proposed Home Ward workforce are given in Section 7
below. The planned workforce provides for essential leadership and
organisation capacity to enable rapid growth in a complex new service to
meet anticipated demand for a scaled up service across Lambeth and
Southwark. In addition, the workforce design provides capacity to
develop the whole staff team to cope with new clinical demands, acute
interventions, to increase efficiency whilst maintaining the highest quality
of patient care and to maximise the benefits of multi-disciplinary and
trans-disciplinary working to avoid unnecessary duplication and
streamline visits to patients.
As indicated, the roll-out plan is scalable and the implementation plan
will identify timescales for posts to be recruited. Initially, core members
of the new Wards will be appointed to spend time with the existing
Wards and hospital bases, and to establish the service, with growth of
the team matching the anticipated number of referrals and beds
available. This will also allow any related adjustments to the community
nursing establishment to be identified.
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5.5
Education and Training
5.5.1
Providing a high quality care service requires a high standard of
education training and support of the workforce. In the establishing the
Pilot this focused on preparing for change, new models, processes and
protocols for delivering care, developing key clinical competencies and
recording activities associated with Home ward’s patient population.
5.5.2
The training programme and competency framework has been
reviewed and is being updated to take account of learning from the Pilot
and to reflect, the GSTT@Home conditions for success (see Section 1
above). It will include: understanding and communicating the nature and
objectives of the GSTT@Home service, and managing professional and
service users’ expectations. This will include communication skills and
elements of ‘customer care’ training thereby acknowledging a more
contemporary approach to the relationships between health professionals
and people using the services as well as other agencies and care
providers who will also count as our consumers in a more commerciallyminded NHS. It will include developing further effective interdisciplinary
and trans-disciplinary team working including holistic and joint
assessment, sharing information, understanding roles and identifying
opportunities to reduce repetition and duplication of effort, and preparing
and making case presentations within the multidisciplinary team.
5.5.3
Therapy skills – in addition to dedicated therapist professional
competencies the wider MDT will have greater awareness of indications
for Therapy input, the identification of need, appropriate provision and
fitting of equipment and walking aids, reviewing a patient’s mobility and
assessing patients within their home environment.
5.5.4
Nursing skills – non-invasive nursing skills - for Nursing Assistants under supervision, such as understanding the provision and use of
assisted medication devices, understanding medication charts and
medication labelling, monitoring and taking blood pressure and assisting
a person with catheter care, reviewing pressure areas and monitoring
blood sugars.
5.5.5
The workforce model also provides scope to develop new roles across
health and social care.
5.6
IT and communications
5.6.1
A full ICT specification will be developed as part of the implementation
plan to include the need for more integrated systems, protocols and
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improved access and the ability to upload notes on RIO without going
back to base and a review of RIO process maps and guidance.
5.6.2
Systems will be developed to provide improved performance
management of staff activity with patients, record more reliably the
reasons and sources for referral and capture principle diagnoses and
relevant co-morbidity.
5.6.3
Access to EPR, EMIS and other systems containing patient data is being
looked at more widely and the specification will reflect any agreed new
developments. In the interim efficient access remotely to enhance
patient care is crucial. The use of tablets, blackberrys or equivalent with
appropriate training will be an important part of establishing the
infrastructure for this growing geographically dispersed, mobile service.
5.6.4
Access to the new SLIC equipped communication hubs and the use of
WebX for teleconferencing will be necessary for interactive
multidisciplinary meetings to engage key people who are unable to be
present.
5.6.5
Training and IT support for novices and practitioners who will otherwise
never be competent with IT to the level needed, will require additional
scoping.
5.6.6
The ICT plan will also reflect current cross-Trust, and SLIC progress and
opportunities for the use of telemedicine, telehealth, telecare, assistive
technology, lone worker personal alarms, centralised IT/clinical support
and monitoring patients remotely including early warning systems.
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6.
HOME WARD IMPLEMENTATION – DEMAND, CAPACITY,
OCCUPANCY
6.5.1
Accurately predicting the demand and potential activity for Home Ward is
difficult and complex. The following calculations have drawn on: available
demographic data showing trends that will impact on GSTT @ Home and
related services; the use of HW (including demographic breakdown)
during the Pilot and scaling this up for cross Lambeth and Southwark
coverage; data related to nursing home residents attendance to
Emergency Departments and admissions; expected service growth due
to greater awareness and availability of GSTT @ Home, and activity
projections based on clinical assessment of suitable patients with longterm conditions and other ambulatory care sensitive conditions.
6.5.2
Referrals to Home Ward during the pilot phase have come from:
6.5.3

GPs - referral for monitoring or interventions outside the range of
care currently provided by District Nurses and Community Matrons,
that would otherwise require an unplanned hospital admission.

Hospital clinical teams - when the patient is clinically stable but
treatment and monitoring is required to expedite a discharge or
prevent an admission that is outside the current scope of District
Nurses or community services.

Through predictive risk identification or review by Community
Matrons with GPs - of patients usually with long-term conditions
who are at an increased risk of admission or readmission.
Data collated from the pilot period July 2012 to February 2013 (after
initial start-up) and an audit of the notes of 50 patients (25 from each
ward) in March 2013 following completed episodes of care, shows:
Table 1 : Age and gender of all referrals – July 2012 February
2013
Age range
Under 60
Over 60
Over 70



%
13.12
86.88
70.39
Gender
Female
Male
%
61.11
38.89
There is no strong relationship between the size of the GP
population and number of referrals received to the service.
The majority of practices with higher referrals have at least 5%
population over 70 years of age.
70.4% of all referrals accepted are over 70 years old.
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Table 2 : Sources of referral – July 2012 February 2013
Sources of referral
Community and Primary Care
Hospital
6.5.4
%
54
46
Significant potential demand from nursing homes is shown by data on
A/E attendances and admissions in 2011/12 (provided by
commissioners):
Table 3 : Potential referral to GSTT @ Home from nursing homes
Emergency Lambeth
Southwark
dept.
attendances
759
KCH 447
KCH 154
GST 123
GST 35
Total 570
Total 189
6.5.5
% admitted
59%
Based on the patient level detail, several key areas of activity emerge for
GSTT @ Home, which will be pursued in liaison with the Care Home
Support Team:
 increasing use of A&E diversion schemes given majority of residents
are transferred via London Ambulance Services;
 ensuring nursing homes are fully aware of the range of admission
avoidance services in place;
 care of people with catheters, ensuring staff are trained in risk
assessment and catheter management and that catheter
management plans are in place;
 recognition and management of infection at earlier stage to prevent
escalation to A&E, especially for urinary tract and chest infections;
 management of symptoms and gastroenteritis and dehydration;
 augmenting End of Life care services where additional interventions
supporting symptom management may be required to improve the
quality of life.
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Patient conditions and clinical interventions in the pilot population reflect
the age demographic, but may be expected to both widen and include a
greater number of frail elderly, as the sustainability, confidence,
expertise and training of the HW staff team and greater integration with
ERR is developed by the roll-out implementation plan:
Table 4 : Main Patient conditions and clinical interventions
- Audit Sample March 2013
Main diagnosis
%
COPD
26.92%
Cellulitis
19.23%
Pneumonia/influenza
5.77%
UTI
13.46%
Heart Failure
1.92%
Infected foot ulcers
5.77%
Dehydration (various cause)
7.69%
Pyelonephritis
1.92%
Monitoring
3.64%
Other infections*
7.68%
Other
6%
* including: osteomyelitis, gastroenteritis, abscess, viral illness
6.5.7 Long-term conditions
People over 65 living with multiple long term conditions - many with
frailty and functional or cognitive impairment - account for around 60%
of admissions and 70% of bed days in NHS hospitals. Improving their
quality of life and reducing the burden on inpatient services is a priority.
This involves acute care and Community Matrons and GPs identifying
such patients through review and predictive risk stratification,
streamlining health care and social support through strong
multidisciplinary team work, and Home Ward providing interventions
such as IV antibiotics, nebulisers and monitoring which would
traditionally have required hospital admission. If a hospital admission has
occurred supporting appropriate early discharge to continue treatment at
home, benefits the patient and frees up inpatient beds.
6.5.8
One of the largest groups referred to HW are people with an
exacerbation of COPD. In Lambeth COPD admission rates are
statistically similar to the national average. However, almost 40% of
those admitted to hospital for COPD return in 90 days. It is worth noting
that the average length of stay for COPD admissions has reduced since
2011(COPD profiles were published) and during the time HW and other
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Admission Avoidance initiatives have been set up and is now significantly
lower than the national average.
The average length of stay for Southwark COPD admissions has also
reduced since 2011 (COPD profiles were published) and the length of
stay in Southwark is now significantly lower than the national average.
Emergency COPD readmission rates in Southwark are statistically similar
to the national average. However over 40% of those admitted to hospital
for COPD return in 90days. The premature and overall COPD death rates
have not changed since 2011 COPD profiles and remain significantly
higher than the national average, (NHS London Health Programmes –
COPD Pathway Profiles 2012).
There is potential for HW to further reduce readmissions in Lambeth and
Southwark residents with COPD.
6.5.9
Projected number of referrals
Factors influencing the number of referrals made to the service during
the GSTT @ Home roll-out will include:





all GP practices having access to the service;
the impact of the hospital-based case finding roles;
more systematic service promotion in primary care, community
services - including nursing and residential homes, secondary care;
a more robust infrastructure;
the impact of a dedicated leadership role for Home Ward Department.
6.5.10 Projections have used referrals to date and applied these to the total GP
practice populations. Before adjustment for disease incidence and
prevalence, and deprivation indices, the projected range of referrals is
shown in Fig 5 below:
Table 5 : Pilot referrals projected to whole population
Projection
Pilot referrals projected to total
population (709,532)
As above, top 10 pilot GP practices
projected to total population
Pilot referrals <70 and >70 projected to
total population <70 and >70
Projected demand per annum
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7 months
1845
12 months
3162
2554
4379
1992
3414
3162 – 4379 referrals
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6.5.11 Future patient pathway-based projections
Discussions with senior clinicians expressed a view that overemphasising single conditions as a basis for assessing ‘volume’ was
unwise, as the majority of patients particularly over 70 (the largest
group to use Home Ward to date) will have more than one if not multiple
conditions affecting their treatment plan. The general view being that
the interventions required and confidence in which these can safely be
delivered holistically at home by GSTT @Home (which has grown through
the Pilot phase) will prompt referrals for admission avoidance and early
discharge for a population that would otherwise require a hospital stay.
Nevertheless, an activity analysis under way, is stimulating discussion
and will provide the basis for making admissions avoidance impact
estimates. The activity analysis work in progress is given in Appendix 1
below to indicate the widening scope of conditions and interventions that
senior clinicians are discussing. It includes outcomes of a workshop and
further discussions with clinicians. It is currently being analysed by SLIC
to calculate impact estimates. It is notable that these discussions have
identified a significantly wider range of conditions suitable for
GSTT@Home than have hitherto been referred.
It is clear that GSTT@Home can have a significant impact in the following
areas:
a) reducing admissions from nursing homes
b) reducing COPD re-admissions
c) reducing admissions for other long-term conditions
d) reducing length of stay.
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6.5.12 Service capacity projection
Table 7 : HW bed capacity projection
Number of Home
Wards
Total number of
beds
GP-registered
patient population
served
GP surgeries served
Current pilot
phase
Phase 1
implementation
Phase 2 if required
2
4
6
Maximum 50
inc. case
management
202,000 as at
12/12
100*
120 – 140
709,532
709,532 to be
adjusted for date
25 at 12/12
circa 99
99
* additional beds possible, if risk assessment and resources allow
Table 8 : Target HW referrals and occupancy
– Phase 1 implementation
Per day
Initial target referrals per ward
Initial target referrals
HW Department
Target average length of stay
Target occupied bed days
Total HW bed days available
Per month
Per year
3
90
1095
12
360
4380
5-7 days
60 - 84
1800 - 2520
21 900 – 30 660
80 - 100
2400 - 3000
29 200 – 36 500
Initial target occupancy
80%
6.5.13 The number of patients referred and numbers of bed days (or hours)
saved will be key indicators of HW performance. Any patients needing to
stay longer than 10 days would be identified ahead of MDT meetings and
either agreed to be an exception, with rationale recorded, or if
appropriate transferred for case management or to District Nursing.
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7.
FINANCIAL CASE
7.1
Costing of Phase 1 HW implementation
7.1.1
Previous HW implementation options costs were considered by the
Admission Avoidance Programme Board in October 2012, following which
additional work on the business case was commissioned. The proposals
at that time centred on providing a Ward in each of the seven localities.
7.1.2
It is important to note that the HW implementation includes the
infrastructure and associated front-loaded investment necessary to
develop HW capacity, accelerate the numbers of patients able to access
the service, reduce length of stay where appropriate and increase service
turnover.
7.1.3
Recurrent costs
The costs of establishing GSTT@Home are in the process of being
finalised. The current service is funded by commissioners from
reinvested readmission monies. In order to provide an equitable, high
quality service across Lambeth and Southwark and to achieve a level of
financial savings (based on bed days saved as outlined in Table 10),
stable recurrent funding will be needed to support the creation of a welltrained, experienced and stable workforce, with a suitable infrastructure
for a scalable service, at the following level:
Table 9.1 : Recurrent costs Phase 1 implementation
Pay costs
Community Services paid direct (inc.
£
2,997,411
acute posts and MDT consultant sessions)
Social services
Home Ward GPs*
Pharmacy
Total pay costs
76,000
222,824
59,069
3,355,304
Total non-pay costs
466,911
On-costs pay and non-pay at 10%
382,221
TOTAL PAY AND NON-PAY RECURRENT COSTS
4,204,436
* includes provisional allowance to cover 3.00pm to 6.30pm. The GP costs
currently provided by SELDOC will need to be renegotiated when Home Ward
moves to a new service model. It is assumed that this will be a shared care
model, working 8.00 am-6.30pm.
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7.1.4
Confidential
Funding mechanism
Commissioners intend to link the funding mechanism to achieving a
change in acute patient and treatment pathways. They also anticipate
that the mechanism will link to reduction on the use of Medihome for
local patients by KCH. Discussions are underway within the SLIC finance
and contracting reference group to develop the contract process to be
used and to agree the source of funds. These are likely to include:
 admission avoidance/readmission reinvestment;
 Southwark and Lambeth Integrated Care (SLIC) funds, as
GSTT@Home is a key development in meeting objectives;
 spend by acute providers for Lambeth and Southwark residents.
In view of the fact that this is a major development requiring a big
culture change, as already acknowledged by many stakeholders, a
strategic approach to revenue funding will be required, rather than
narrowly target-based, for the first two years.
In addition it is proposed that the Community Service Directorate
becomes the lead contractor for the GSTT@Home service rather than
commissioners directly funding some aspects such as GP services, social
services. This will help clarify and simplify the contracting process,
strengthen management oversight and enable commissioners to focus on
overall value and service outcomes to meet corporate objectives.
7.1.5
Non-recurrent set-up costs
Non-recurrent funding, to pump-prime the set up of this major new
community service, is being sought from commissioners. Non-recurrent
costs are estimated as follows:
Table 9.2 : Non-recurrent costs Phase 1 implementation
TOTAL NON-RECURRENT SET-UP COSTS
(for details see Appendix 7)
£
486,685
This sum will allow the set-up of four substantive wards, geographically
located N/S/W/E to provide accessible and cost effective cover, plus two
acute bases within the hospitals, and a central administration (which
may be co-located with one of the wards).
Final non-recurrent costings for set-up will depend on the outcome of the
space utilisation review and confirmation of the location of the four
wards, plus more technical analysis of the IT/telecommunications
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systems required. It should be noted that the non-recurrent set-up
funding will be disbursed over the first two years 2013-15 of the
development of the service.
7.2
Return on investment
7.2.1
The business case is presented on the basis that there is a clear and
pressing need to provide an equitable service for all who will benefit from
Home Ward across Lambeth and Southwark. The implementation will be
informed by activity modelling and the intensity and scope of specified
patient pathways and a range of interventions. The service will be
delivered by an MDT with experience of delivering care in the patients’
most familiar environment – their home (including care and residential).
7.2.2
An efficient patient flow through A/E, EMU and acute medicine at GST
and KCH is a success factor for King’s Health Partnership (KHP). For a
number of patients with certain conditions and who are clinically stable,
prolonged length of stay is often influenced by the frequency and
monitoring of treatments required and time taken for a series of tests to
be carried out. Reducing unnecessary hold ups will be a key HW/ED
objective.
7.2.3
The provision of a Trust-wide Home Ward will ensure acute and
community services collaboratively develop more robust pathways for
admission avoidance and advanced discharge for all adults. It will also
meet broad strategic objectives and deliver a range of benefits (see
Section 4 above), as well as contributing to the following investment
objectives:
a) releasing bed capacity;
b) reducing length of stay and early readmissions;
c) meeting a gap in current community services of an inequitable
service;
d) contributing to the transformation of community nursing;
e) ensuring the highest level of patient care and carer satisfaction
provided by GSTT and KCH.
7.2.4
In terms of the key measure of hospital bed days saved, the March 2013
audit showed 50 ‘typical’ patients in the categories early discharge and
admission avoidance as saving 284 hospital in-patient bed days,
or 5.68 bed days per patient.
7.2.5
At full capacity, Home Ward will be able to accept 6,083 admissions a
year (based on an average length of stay of 6 days). On this basis,
potential financial savings compared to PbR tariff from Phase 1 of Home
Ward roll-out may be realised as follows:
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Table 10 :
Potential maximum cost savings - Phase 1 of Home Ward implementation
Initial
Target
Occupancy Rate
Bed Days p.a.
Admissions p.a. (average LoS = 6 days)
Revenue cost of GSTT@Home
Hospital bed days saved (5.68 days average LoS)
Potential Admissions Avoided*
Estimated current charge under PbR (@ weighted
average of £2,003 per spell)
Potential saving compared to current tariff
*some will be early discharges
7.2.6
80%
29,200
4,867
£4,204,436
100%
36,500
6,083
£4,204,436
27,645
4,867
34,551
6,083
£9,748,601 £12,184,249
£5,544,165
£7,979,813
In addition to the potential to release significant savings for the Trust,
the proposals also promise substantial value added to the provision of
the Home Ward service, including:









7.2.7
Full Capacity
decades of experience in Lambeth/Southwark;
integrated Trust and established governance;
established relationships with GPs, commissioners, social services,
Local Authorities and voluntary agencies;
more stable and flexible service than anything outsourced;
builds on existing cross-Trust and KCH models (e.g. SPC, Neurology,
respiratory team);
service is part of KHP;
any savings remain within the local health economy;
retains the integrity of the GST brand, rather than its adding value to
other businesses;
allows GSTT@Home to use outsourced solutions to add further
capacity if necessary, and if this offers value for money.
A comparison of costs with Medihome is provided below (*based on a
figure from an out of London example), although there are several noncomparable factors, such as:

uncosted KHP support for bought-in services;
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

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Home Ward is designed to be scalable to 120 beds or more, with
reducing infrastructure apportionment as service grows;
broader value added for KHP of in-house Home Ward service,
including development of community services;
longer term costs of failure to develop an in-house service providing
urgent acute care in the community.
Table 11 :
Comparison of financial costs of Home Ward with Medihome
Home Ward roll-out Medihome*
Annual cost of
100 beds
Annual cost of
100 beds
£
£
-
Fixed annual cost for beds
alone
Annual cost for four Home
Wards plus central
administration, practice
development roles, two
acute bases, pharmacy etc.
5 280 000*
4,204,436
*Medihome price is illustrative and based on an out-of-London example,
and excludes pharmacy, pathology services and accommodation.
7.2.8
GSTT@Home has the potential to provide high quality, safe patient care,
make substantial savings for the health-care economy, and to release
acute capacity, at the same time as adding value to the patient
experience and clinical outcomes. It appears to be a substantially better
investment for the Trust than commercial competition, not only
financially, but also in taking a higher percentage of complex patients
and offering integrated care with other acute and community services,
Social Services, voluntary and other providers. In addition, once care is
transferred to GSTT@Home, at present it counts as a discharge at the
point of transfer, whereas with Medihome discharge occurs at the end of
the Medihome service. GSTT@Home could make a significant
contribution to the GSTT strategy of ‘Fit for the Future’, and will be a
major element in the transformation of Community Services.
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IMPLEMENTATION PLAN
Senior management’s objective is to ensure GSTT@Home department,
comprising four wards plus GST and KCH bases, is operational by
November 2013 in order to support winter pressures. However, the
implementation planning (Appendix 2) indicates that such an outcome
is dependent on full funding and reducing the standard GSTT timescale
for recruitment of key posts. Consideration should therefore be given to:
1
headhunting key posts using an external recruitment agency;
2
escalating the recruitment process from the existing staff team,
whilst also adhering to best practice.
In addition, the scope of the service upgrade and expansion that is
envisaged, involving as it does significant development in the community
services culture, plus a period of growing multi-disciplinary
understanding, confidence and team-building across acute and primary
care, indicates that there will be significant development period beyond
initial launch for the service to meet its full potential.
The development and full use of IT and electronic communications, which
will be necessary for the full potential of GSTT@Home to be realised, will
also require an extended lead time, and a dedicated IT development lead
within support services.
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Confidential
COMMUNICATIONS PLAN
The effective communication of the GSTT@Home service to all key
stakeholder groups will be crucial to successful implementation. Some
work has already been done during the Pilot and business planning stages,
and it is clear that most audiences readily understand the vision and
benefits of the expanded service. More detailed communication of the
targeted conditions and interventions, the new organisation structures and
processes, and the referrals procedure will be essential.
The objectives of the Home Ward communication plan (Appendix 3) are
as follows:
 To communicate clearly and consistently the vision, background,
benefits, scope, model and conditions for success of the GSTT @Home
service
 To address stakeholders’ questions and concerns, and to incorporate
their feedback where relevant
 To ensure safe and successful implementation of the new GSTT
@Home service
 To maximise the usage of the GSTT@Home service
 To communicate effectively the presence and values of GSTT and the
@Home service across Lambeth and Southwark via consistent and
professional branding
 To ensure that all previous communications not consistent with the
proposed service are withdrawn
 To refine this plan and work in collaboration with the Communications
Department to achieve the above objectives
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HOME WARD (GSTT@Home) INITIAL RISK ANALYSIS
An initial Risk Analysis has been carried out for the implementation of the
GSTT@Home service (Appendix 4). A full clinical risk analysis will also
be carried out.
A number of key implementation, organisational and clinical risks have
been identified and evaluated as to likelihood and consequence. It is
judged that once funded, the most significant risk to the successful
implementation of the service is that of potential delays in recruitment,
IT development, procurement and estates, for a complex and large
development project with a tight implementation timetable.
Negotiation with support services at the highest appropriate level needs
to begin without delay, to establish clear one-stop liaison arrangements
for each service and shared accountability for meeting deadlines. Close
senior management oversight of the implementation, and contingency
planning in the face of events, will also be important.
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Appendix 1
HOME WARD (GSTT@HOME) ACTIVITY ANALYSIS:
Potential Impact Of GSTT@Home On Emergency Admissions
(and Reduced Length Of Stay) Of People Aged 65+
Data from a workshop and discussions with clinicians and assumptions about
potential activity is being analysed to provide impact estimates based on current
acute (and community) activity related to these conditions. This will be
compared with a similar pre-pilot exercise.
= potential conditions
treated by Home Ward
Condition
Condition detail
LTCs
Resp, LTC
Notes
COPD
Other
Asthma
Some from GPs
Chr Resp Failure
CV
HF
AF
HT
GI
Diverticulosis, constipation
If constipation cause known
Ulcer et al
Other
Dysphagia
MSK
Arthropathies
Dorsopathies
Other
Possible if pain control
Osteopathies
Diabetes
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Epilepsy
Parkinson et al
Alzheimers et al
Other
Neph
Chr Renal Failure
Monitoring
Ulcer
Complex, infected and
diabetic ulcers
Skin
GU
Infections
Trauma
BPH
Influenza,
Pneumonia
IV antibiotics/sub-cut
hydration
Other respiratory
IV antibiotics/sub-cut
hydration
UTI
IV antibiotics/sub-cut
hydration
Skin
Cellulitis
Septicaemia
IV antibiotics/sub-cut
hydration
GI
IV antibiotics/sub-cut
hydration
Fracture, Hip &
Thigh
Other wounds
and injuries
Reduce LOS
Fracture, Upper
Limb
Senility with Falls
Fracture, Pelvis &
Spine
Fracture,
Knee/Lower Leg
Fracture, Other
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Fracture, Foot &
Ankle
CV event
Stroke, CVA
Reduce LOS
Chest pain
Angina
Other IHD
Other
MI
PE
Minor PE
TIA
DVT
Some
Arterial
thrombosis
Cancer
GI
GU
Resp
Post-op, end of life,
supporting other services
Other
Lympho/Haemato
ill-defined,
secondary
Breast
Brain
GI
Non-infective
inflammation
Other
Hepatobiliary
Reduce LOS
Abdo pain
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Hernia
Mental/cognitive
Nausea &
Vomiting
Disorientation,
dizziness
If infective
Senility Other
Dementia
Reduce LOS or avoid AA,
depending on presenting
condition
Delirium
Reduce LOS or avoid AA,
depending on cause
Intoxication
Anxiety,
Depression
CV
Syncope
Hypotension
Valve disorders
Aneurysm
Organ failure et
al
GU
Acute Renal
Failure
Pleural Effusion
& Ascites
If chronic, and reduce LOS
Liver Failure
Some
Acute Resp
Failure
Depending on cause
Haematuria
Poss monitoring post-trauma
Urinary retention
Calculus
Nutrition
Anaemia
Volume
depletion
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Other
Malnutrition,
deficiencies,
obesity
Other anaemia
Electrolyte/Fluid
Sub-cut hydration
Shortness of
Breath
Epistaxis
Convulsions
Headache
Ophthalmic postop
Monitoring, medication
End of Life
Augmenting other services
Other
Subject to further analysis
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Appendix 2
HOME WARD (GSTT@HOME) IMPLEMENTATION PLAN
Area of Activity
Tasks
Lead
1. Pilot completion
Update issue log and resolve outstanding
items
 Create Master data base and
hard copy of existing policies,
protocols and other key
documentation.
 Complete any outstanding IPC,
clinical and IT training
 Agree anti-microbial screening
and IV audit programme
 Staff consultation
 Predictive score use and training
needs
 Review membership, Terms of
Reference and meeting schedule
for Work Streams to support
implementation.
Present business case and budget to
Commissioners and SLIC finance and
contracting group
1.
negotiate and agree contract
2.
develop and agree KPIs
Develop communications plan for key
stakeholder groups, inc. users/potential users
PG/CS
2. Contracting
2. Communications
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Days
35
Start date
End date
6 May 2013
30 June 2013
ES
21
24 May 2013
21 June 2013
AD
6
29 April 2013
7 May 2013
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Area of Activity
Tasks
Lead
3. Governance
Develop and approve terms of reference and
membership for organisational structures:
 Steering Group
 Management Group
 Clinical Reference Group
Define service audit and evaluation processes
1. Review existing processes and identify
potential ones for discussion at the new
Clinical Reference Group
Staff consultation process to be defined
Write/review job descriptions and person
specifications for all roles
Identify designated HR account mgr
Job evaluation
Recruit management team/specialists:
 Set interview dates
 Advertise vacancies
 Shortlist
 Interview
 Offer
 Notice period/CRBs
 New starters/induction
Recruit staff/non-specialist:
 Set interview dates
 Advertise vacancies
 Shortlist
 Interview
 Offer
 Notice period/CRBs
 New starters/induction
PG
4. HR recruitment
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Start date
End date
21
3 June 2013
1 July 2013
CS
14
12 June 2013
1 July 2013
PG
CS
3
15
17 May 2012
24 May 2013
22 May 2013
14 June 2013
TBA
TBA
5
114
1
14
5
15
5
60
5
55
1
15
5
5
1
24
5
17 June 2013
24 June 2013
21 June 2013
28 November 2013
9 September 2013
28 November 2013
TBA
Days
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Area of Activity
Tasks
Lead
5. Policy and clinical
systems
Review and develop clinical protocols
inc.patient pathways programme
Review patient profiles, admissions,discharges
Define medical, nursing and therapy profiles
Review and update operational policies inc.
medical model
Review and update clinical systems and
processes
Policies approval and governance
Specify accommodation and facilities
requirements for each location
Accommodation/location identification
Specify modifications/refurbishment for each
location
Scoping IT infrastructure inc. teleconferencing
and patient monitoring
Submit request to SLCSU IT PM request
Submit ICT Business Outcome Request
Submit New requirement form & RIO training
Undertake any refurbishment works
Specify furniture, fixtures and fittings
Install furniture, fixtures and fittings
Specify and procure medical equipment
Specify and procure IT, telecoms and office
equipment
Review and define competencies and training
(incl IT) needs for all roles
Devise training programmes
Develop evaluation processes and timeframes
Deliver initial training required (incl IT)
6. Estates and facilities
7. Equipment
8. Education and
training
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Days
Start date
End date
CS
29
3 June 2013
11 July 2013
CS
CS/CI
CS
29
29
21
3 June 2013
3 June 2013
15 April 2013
11 July 2013
11 July 2013
14 May 2013
CS
21
3 June 2013
1 July 2013
HR/YB
PG
10
8
12 July 2013
27 May 2013
26 July 2013
5 June 2013
PG
PG
10
5
6 June 2013
19 June 2013
19 June 2013
25 June 2013
PG
8
19 June 2013
28 June 2013
8 May 2013
8 May 2013
TBA
20 June 13
TBA
6 June 2013
6 June 2013
14 May 2013
14 May 2013
PG
PG
PG
TBA
CS/CI
TBA
CS
PG
3
4
3
TBA
5
TBA
35
52
26 June 2013
2 September 2013
24 July 2013
16 August 2013
CS/CI
15
24 May 2013
14 June 2013
CS/CI
CS/CI
CS/CI
15
15
28
17 June 2013
9 July 2013
28 November 2013
8 July 2013
29 July 2013
10 January 2013
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Area of Activity
Tasks
Lead
9. Transport
Specify transport requirements for staff,
samples etc
Option appraisal to meet service activity pool
car(s), driver, taxi for non car user/owner.
Agree ‘brand’, consultation, plan re-launch.
Design service brochures, intranet docs,
internet visuals , CD and other materials
(comparable with market competitors)
Develop, approve, disseminate/train, PR and
communication standards about use and
image of the service
PG
10. PR and marketing
TBC To be confirmed
PG
Days
Start date
End date
19 June 2013
28 June 2013
12
1 July 2013
16 July 2013
45
27 May 2013
29 July 2013
7
TBA To be advised/agreed
Corporate milestones to inform planning
Meeting/event
GST TME
NHS Lambeth CCG Board
 Clinical Commissioning Group
NHS Southwark CCG Board
 Clinical Commissioning Group
Joint Health and Adult Services scrutiny
sub committee
SLIC Programme Board Meeting
 Citizens Board
 Citizens Forum
KCH Management Executive meeting
‘HWRO’ Implementation Steering Group
meetings
‘HWRO’ Clinical Reference Group meetings
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Date
May 2013
1 May, 3 July, 4 Sept
13 June, 11 July, 8 Aug, 12 Sept
Awaiting date
1 May 2013
TBC
TBC
TBA
TBA
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Appendix 3
HOME WARD (GSTT@Home) COMMUNICATIONS PLAN
Key media:
Format
1
Short film about @Home service*,
including how to refer and to use the
service and the difference it can make.
2
Information leaflets and folders, including
how to refer and to use the service
3
Posters and flyers
4
Signposting
5
Presentations
6
Articles
HW Final draft AAPB 13.06.13
Audiences
Users, potential users;
Professionals and referrers
(2 edits)
Users, potential users;
Professionals and referrers
(2 leaflets)
Users, potential users;
Professionals and referrers
(2 forms)
Users, potential users;
Professionals and referrers
Users, potential users;
Professionals and referrers
Users, potential users;
Professionals and referrers
Media
General information DVDs; internet/intranet;
presentations
Hard copy;
internet/intranet;
internal and external information points
Hard copy;
internet/intranet;
internal and external information points
Email formats; letterheads; signage; uniforms;
equipment bags; etc.
Powerpoint; detailed information; presentation
templates; knowledgeable speakers
KHP internal magazines, e communications;
professional press and blogs; local newspapers
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Communication plan:
Audience
Purpose/Content
When/Frequency
How/Media
GST TME
Secure support and decision to implement
roll-out once full funding agreed.
May 2013.
Outline business proposal and
discussion at TME meeting
Kings Health Partners
including SLAM
Secure support, engagement and promote use
of service
June 2013
Presentation; information;
staff bulletins and enewsletters;
SLIC Programme Board
Communicate contribution to SLIC aims and
outcomes; secure support, engagement and
receive feedback
June 2013
Meeting; presentation;
information; website
Commissioners
Communicate contribution to strategic
outcomes; secure support and funding;
engagement and receive feedback
May 2013
Outline business proposal and
budget; meeting and
discussion
Clinical Commissioning
Groups - Lambeth
Communicate contribution to strategic
outcomes; secure support and funding;
engagement and receive feedback
May 2013
Outline business proposal and
budget; meeting and
discussion
Lambeth and Southwark
LMCs
To present Medical Model to support HWRO,
gain support and engagement and highlight
impact on wider Community Services. Receive
feedback.
TBC
Medical Model and associated
operational policy. Discussion
at LMC meeting.
Clinical Commissioning
Groups - Southwark
Communicate contribution to strategic
outcomes; secure support and funding;
engagement and receive feedback
May 2013
Outline business proposal and
budget; meeting and
discussion
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Audience
Purpose/Content
When/Frequency
How/Media
Local Authority/Social
Services - Lambeth
Communicate contribution to strategic
outcomes and shared vision; secure support
and engagement and receive feedback;
identify any shared development and funding
opportunities; potential of joint commissioning
May 2013
Outline business proposal and
budget; meeting and
discussion
Local Authority/Social
Services – Southwark
Communicate contribution to strategic
outcomes and shared vision; secure support
and engagement and receive feedback;
identify any shared development and funding
opportunities; potential of joint commissioning
May 2012
Outline business proposal and
budget; meeting and
discussion
Joint Health and Adult
Services scrutiny subcommittee
If required to present the proposal and receive
feedback as it affects more than one local
authority area, if it is considered "substantial"
by the health scrutiny committees, for those
areas affected by the proposals
TBC
Outline business proposal and
budget; meeting and
discussion respond to any
formal feedback.
GST Community – nurse
and service managers
Provide feedback from the consultation, report
outcomes from presentations to
Commissioners, GST, KHP, SS. Timetable for
implementation plan, implications and
opportunities for current DN, Community and
HW team members.
May/June 2013
Presentation and printed
summary of key content of
OBC and commitment about
updating.
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Audience
Purpose/Content
When/Frequency
How/Media
GST Home Ward – current
staff group, HW,MDTs and
participating clinical
specialist teams
Provide feedback from the consultation which
contributed to OBC, report outcomes from
presentations to Commissioners, GST, KHP,
SS and LAs. Timetable for implementation
plan and implications and opportunities for
streamlining collaborative and joint working.
Receive feedback
May 2013
Presentation and printed
summary of key content of
OBC, and commitment about
updating.
GST ERR and therapy staff
group
Provide feedback from the consultation which
contributed to OBC, report outcomes from
presentations to Commissioners, GST, KHP,
SS and LAs. Explain timetable for
implementation plan and implications and
opportunities for current ERR and HW team
members.
June 2013
Presentation and printed
summary of key content of
OBC, and commitment about
updating.
Staff representative
groups, eg RCN, Unison
Provide feedback from process they have been
observers in as part of AA Programme Board
activity. Agree timetable and process for any
consultation and workforce issues.
July 2013
As advised by HR
GST district nursing teams
and community services
Provide feedback from the Pilot and present
the new GSTT@Home service Explain
timetable for implementation, implications,
benefits and opportunities for current DN and
other community service.
July 2013
‘Road show’ presentations and
supporting material in context
of meetings already set and
special briefings.
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Audience
Purpose/Content
When/Frequency
How/Media
GST clinical departments
– senior staff
Provide feedback from consultation
communicate contribution to shared
objectives, secure support and engagement
and receive feedback. Promote the service
April to June 2013
Presentations and supporting
material in context of meetings
already set and special
briefings
GST clinical departments
– all staff
Communicate the aims and objectives of the
service, contribution to shared objectives,
secure support and engagement and service
use.
September 2013
Presentations and supporting
material in context of meetings
already set and special
briefings.
KCH divisional
management teams and
other key departments
Communicate contribution to shared
objectives, secure support and engagement
and receive feedback. Promote the service
July 2013
Presentations and supporting
material in context of meetings
already set and special
briefings
GST - workforce and
organisational
development
Communicate vision, scope and purpose of
the new service, and include feedback in
programme of work and inter-dependencies
on HR issues, education, training and OD
May/June 2013
Presentation to HR and
organisational development
team leadership team
Communicate vision, scope and purpose of
the new service, conditions for success and
dependence on state of the art IT. Include
feedback in programme of work for IT and
telecomms
May/June 2013
GST - IT
HW Final draft AAPB 13.06.13
September 2013
Work-stream programme.
Joint presentation to IT
leadership team including all
aspects (eg training).
Work-stream programme
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Audience
Purpose/Content
When/Frequency
How/Media
GST - estates and
facilities
Communicate vision, scope and purpose of
the new service, conditions for success and
dependence on estates and facilities to meet
roll out timeframe.
May/June 2013
Presentation to key personnel,
clarification of
GST all other staff
Communicate vision and purpose, secure
engagement. Promote the service
October 2013
‘Road show’ presentations and
supporting material. In house
e and other publicatioms
GP practices
Communicate outcomes of Pilot, vision, scope
and purpose of the new service; contribution
to primary care objectives, secure support and
engagement and receive feedback. Clarify
Home Ward links to Practices and relationship
with existing community services and MDTs.
July to September 2012
‘Road show’ presentations and
supporting material in context
of meetings already set and
special briefings. In house
primary care communications
GST chaplains and other
local ministers of religion
Communicate vision and scope of service
contribution to shared objectives, secure
engagement and receive feedback. Promote
the service
September 2013
‘Road show’ presentations and
supporting material in context
of meetings already set and
special briefings
London Ambulance
Service
Communicate outcomes of Pilot, vision, scope
and purpose of the new service; contribution
to shared objectives, secure support and
engagement and receive feedback. Clarify
Home Ward links to Practices and relationship
with existing community services and MDTs
July to September 2012
‘Road show’ presentations and
supporting material
Involvement in
workstream/reference group
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Audience
Purpose/Content
When/Frequency
How/Media
Local voluntary agencies
Communicate outcomes of Pilot, vision, scope
and purpose of the new service; shared
objectives, secure support and engagement
and receive feedback. Clarify Home Ward links
to Practices and relationship with existing
community services and MDTs
October 2013
Road show’ presentations and
supporting material in context
of meetings already set and
special briefings. Newsletter
articles
Nursing homes
Communicate vision, scope and purpose of
the new service; shared objectives, secure
engagement, use and receive feedback.
Clarify links to Practices and relationship with
existing community services and MDTs
September 2013
Work with Nursing Home
Support Group, utilising
existing communication
channels. ‘Road show’
presentations and briefings
Other hospitals used by
Lambeth and Southwark
residents, eg St George’s,
Tooting
Communicate contribution to shared
objectives, secure support and engagement
and receive feedback. Promote the service
July 2013
Presentation and discussion
with key personnel
Related universities and
colleges, eg LSB
University
Communicate vision, objectives and purpose
of the new service, secure support and
engagement and receive feedback. Identify
joint working and development
June/July 2013
GST Home Ward – current
service users
Communicate purpose of the ‘revised’ service;
and receive feedback. Clarify Home Ward links
to Practices and relationship with existing
community services.
TBA
HW Final draft AAPB 13.06.13
October 2013
Briefings and internal
communication.
Presentation and discussion
with key personnel
Workstream prgramme
Summary information. New
communication materials and
media for users.
Incorporate feedback
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Audience
Purpose/Content
When/Frequency
How/Media
User groups
To inform and receive feedback on the Model
and ‘brand’. Communicate vision, purpose of
service. Clarify links to Practices and
relationship with existing community services.
June to September
2013
PALS communications
Local MPs and councillors
Communicate vision, purpose of a
SLIC/GSTT/KHP initiative. Clarify links to
Practices and relationship with existing
community services.
TBA
TBA
General public Lambeth
and Southwark, eg:
- SLIC Citizens Board
- SLIC Citizens Forum
Communicate vision, purpose and how service
operates and is a SLIC/GSTT initiative. Clarify
links to Practices and relationship with existing
community services.
TBA
Local paper articles
Local newsletters
Libraries posters
CAB resources Presentations
Professional bodies and
journals
Communicate vision, purpose and how service
operates and is a SLIC/GSTT initiative.
TBA
Clinical reference Group
discussion
Identify aspects of interest to communicate
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Other TBC
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Appendix 4
HOME WARD (GSTT@Home) INITIAL RISK ANALYSIS
Risk level:
High
Medium
Low
Risk
Likelihood
1-5
Consequence Risk
1-5
level
Mitigating action
1
Inadequate funding or support for
complete implementation
3
4
12
Present convincing case
Scalable model
2
Delays in recruitment, IT development,
procurement, estates
4
4
16
Realistic implementation timescales
negotiated with support services.
Close senior management oversight of
implementation
Contingency plan
3
Failure to recruit suitably qualified
clinical service leadership
4
3
12
Start recruitment immediately
Rigorous person specification
Salary reflects complexity and demands of
role
External recruitment
Adjust project timescales to recruitment
Retain/second project management
oversight until leadership recruited
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Risk
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Likelihood
1-5
Consequence Risk
1-5
level
Mitigating action
4
Failure to recruit suitably qualified
nurses, therapists, GPs, PAMS, business
support
3
4
12
Start recruitment immediately
Rigorous person specifications
Internal/external recruitment
Acute/community rotation option
Adjust project timescales to recruitment
Retain/second project management
oversight until leadership recruited
5
Demand outstrips capacity
3
3
9
Manage length of stay
Manage onward referral
Scaleable model - expand beds and recruit
more staff
Make case for further investment
6
Slow take-up of service in referrals
2
3
6
Managing management expectations
Systematic case-finding in acute and
community
Systematic promotion of service, including
its rigour, to all referrers and user groups
Working closely with related professionals
eg discharge teams, consultants, GPs
7
Lack of strategic clarity leading to
simultaneous use of commercial
competition which undermines
GSTT@Home service
3
4
12
Communicate risks and impact of
commercial competition, eg use of GSTT
brand, recruitment of experienced staff,
confusing publicity to referrers and users;
GSTT and KCH avoid use of directly
competing services for same patient groups
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Risk
Confidential
Likelihood
1-5
Consequence Risk
1-5
level
Mitigating action
8
Inappropriate patients referred
2
2
4
Education of referrers about criteria and
patient pathways
Managing expectations of referrers and
patients
GSTT@Home staff trained to refer on
Referral process uses prompt questions to
identify unsuitability in patient or
environment
9
Clinical errors/poor outcomes
2
5
10
Effective clinical governance
Establishing exemplary clinical
competencies, policies and protocols
tailored to the environment
Close working with infection prevention and
control, and with pharmacy
Rigorous recruitment and training
Integrated record-keeping for real-time
oversight
Rigorous supervision, case review and
reflective practice
Holistic culture rather than task-oriented
practice
Early warning and monitoring systems
Patient and carer education about potential
difficulties and emergency calling
Nurse training in clinical emergencies
Appropriate equipment always available
Effective communications equipment
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Risk
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Likelihood
Mitigating action
1-5
Consequence Risk
level
1-5
10
Patient safeguarding
1
4
4
Adherence to GSTT safeguarding policies
and training, in particular relating to lone
working
Effective supervision and management
Identifying and oversight of high risk
situations Attunement of staff groups to
one another
11
Staff safeguarding
3
3
9
Adherence to GSTT safeguarding policies
and training, in particular relating to line
working and personal safety
Effective supervision and management
Identifying and oversight of high risk
situations Provision of appropriate
equipment, communications technology and
transport
12
Ineffective IT systems
4
3
12
Design and implementation of suitable IT
systems and service levels tailored for
rapid-response, high risk, high profile,
distributed, mobile service
Business continuity plan for IT and comms
failures
Dedicated IT Account Manager for
GSTT@Home service
Effective staff recruitment and training in
use of IT and comms systems
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Appendix 5
HOME WARD CASE STUDIES
Case study 1:
Enabling Mrs A to recover at home
Mrs A was a previously fit 53 year old who was well on her way to completing
her final law exams and looking forward to embarking on a new career.
Unfortunately, after a short illness resulting in an admission to King’s College
Hospital, she received the devastating news that the doctors had found a bowel
cancer. What followed was a series of bowel operations, the last of which was
complicated by a serious infection. She spent over two months in hospital and
was becoming despondent at the repeated set-backs in her recovery. By this
time she had lost a great deal of weight and had also lost confidence in her
ability to manage in the future.
At this stage she still had a large internal fluid collection that was draining into a
‘bag’ on her abdomen. Her surgeons felt it safer for her to stay in hospital in
order that they could monitor the amount of pus that was draining, however Mrs
A was desperate to return home. Reassured after a conversation with the Home
Ward GP, the surgical team were happy for her to return home to recover under
Home Ward care.
On arrival at home she was met by the Home Ward physiotherapist who
assessed her home environment and physical abilities. Due to her prolonged
hospital stay she was physically weak and unable to manage stairs. The
physiotherapist felt she would temporarily require a microenvironment and
arranged for the necessary equipment to be delivered the same day.
Once set up at home she received daily nursing visits to measure the drainage
from her internal collection and to check for signs of worsening infection. She
had regular blood tests and the team provided feedback to the surgeons on a
regular basis. Mrs A made a steady recovery and once the collection had drained
she was reviewed by the surgical clinic and the drainage tube removed.
During her stay with Home Ward she continued to be supported by the
physiotherapist for exercises to improve her strength and fitness. Mrs A initially
required a Home Ward support worker to help with personal care but quickly
regained her independence and confidence and is now looking forward to getting
back to her studies. She was very grateful that Home Ward had enabled her to
return home earlier than expected.
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Case study 2:
Preventing Mr B’s readmission and supporting his preferred place of
care.
Mr B an 88 year old gentleman, was very unwell having being diagnosed with
Cancer of the Prostate and bone secondaries. He lives with a partner Val who is
his full-time carer and who he had gone to stay with after being abused by his
own family. She was finding it increasingly difficult to cope with his rapid
deterioration in health. Mr B had been in hospital with yet another urinary tract
infection causing confusion. On discharge from hospital on the Tuesday, Val was
concerned as when he arrived home in the ambulance he was still confused and
recognised neither her nor his home.
The next day Mr B’s condition worsened. He was becoming increasingly confused
and disorientated. Having previously expressed a wish not to return to hospital
his carer was keen to explore other options. The Community Matron visited and
tried to fast track Mr B to see the Consultant Geriatrician at the hospital. The
consultant advised that he would be able to see Mr B on the Friday however Val
felt both unable to cope and that something needed to be done sooner. The
consultant thought a referral to the Home Ward would therefore be appropriate.
The Home Ward team were able to visit to assess Mr B within 2 hours of
receiving the referral. On arrival Mr B was in bed, drowsy and refusing food and
fluids. We felt that dehydration was exacerbating his confusion. His partner was
understandably upset and becoming distraught and felt unable to cope alone.
The Home Ward Nurses commenced IV fluids on Thursday evening and after
further liaison with St Christopher’s Hospice, Community Palliative Care and the
Community Matron we were able to arrange a sitter to help look after Mr B
overnight.
He was reviewed again by the Home Ward team the next morning. They found
Mr B sitting up-right in his bed, able to communicate, having been washed and
freshened up by the rapid response Support Worker and eating his breakfast.
The Home Ward visited a further couple of times to monitor progress and then
handed the care of Mr B back to the Community Matron and the Palliative Care
Team. Mr B was very pleased that a hospital re-admission had been avoided and
Val was very grateful that we found a way to respect his wishes without
compromising the level of care he received.
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Case study 3:
Helping Mrs C avoid yet another hospital admission
Mrs C, 58, has a long and complicated medical history. Her problems include a
long-term tracheotomy placed in 2005 for upper airway obstruction, COPD
(Chronic Obstructive Pulmonary Disease), CCF (Congestive Cardiac Failure),
hypertension and obesity. As a consequence of this she has had numerous A&E
attendances, ambulance call-outs and hospital admissions over the past few
years peaking at about 1-2 per month for the year 2011.
Following yet another admission to St Thomas’s, with an exacerbation of COPD
complicated by an infection requiring IV antibiotics, the COPD outreach team
referred Mrs C to the newly opened Home Ward team when she was discharged.
The Home Ward team visited to do a holistic advanced health assessment. We
visited three times daily over the next 2 weeks to provide support, monitor her
observations and provide continued education about her illness and self
management. A plan was made about what she should do in the event of a
repeat deterioration in her health.
Mrs C was referred to our care by her GP on a further 5 occasions in 2012. With
Home Ward support on each of these occasions a hospital admission was
avoided. We worked closely with her respiratory consultant and the microbiology
team to provide appropriate IV antibiotics and support in her home when
needed. Her total hospital attendance for 2012 was 3, a great reduction from 1-2
times per month in 2011.
Mrs C is delighted and enthusiastic about her care with the Home Ward team.
She states that simply knowing we are there to care for her when needed
relieves a lot of her anxiety about her long term conditions. She has learnt to
recognise the signs of deterioration in her health early and the GP knows to
contact the Home Ward team as the first port of call. Her latest clinic letter from
St Thomas’s consultant clinic states:
‘I am pleased to hear of [Mrs C’s] recent progress and, in fact, since being
managed by the Home Ward she has remained out of hospital for the last couple
of months.
I think we are now on a very positive path. She feels much better and the
intravenous antibiotic use in the community seems to have prevented further
hospital admissions and improved her own health perception.
I am very
impressed with her progress. I think we should carry on with the current
management.’
(Consultant Respiratory Physician, GSTT)
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Appendix 6
EQUALITY AND EQUITY IMPACT ASSESSMENT INITIAL SCREENING
Initial screening template
1. Policy aims
1.1
Proposal, service, programme,
strategy or procedure being assessed
Home Ward Implemention - Community Services
(GSTT@Home)
1.2
Name of person responsible (policy
manager) and contact details
1.3
Is this a new, existing or revised
policy/function
Development of a substantive service following a Pilot
1.5
What does this policy, service,
programme, strategy intend to
achieve?
The purpose of this service is to provide safe acute
care for Adults in their own home (including Nursing
Homes) across Lambeth and Southwark - that would
otherwise be provided in hospital, thus enhancing
Community Services and in doing so deliver improved
clinical outcomes, continuity of care and enhancing
the patient experience.
The preferred option (following earlier option
appraisals considered by the Admission Avoidance
Programme Board) is that the service be established
across 4 ‘virtual community based wards’ and hospital
posts in both GTS and in KCH), serving residents in
Lambeth and Southwark. A process of consultation
will be put in place to ensure all staff are informed of
the proposal and to allow any employees including
those involved in the Pilot the opportunity to respond
and take an active role in this development/review.
1.6
How does this fit into wider strategic
objectives/priorities?
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Lambeth and Southwark commissioners support
establishing such a service to respond to the national
NHS Quality, Innovation, Productivity and Prevention
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programme (QIPP) which seeks to improve quality
and reduce unnecessary hospital admissions and
costs.
For the Trust, avoiding an admission or the early
discharge from a hospital admission will release
capacity in acute beds to support elective and
unavoidable admissions in St Thomas’ and Guys
Hospitals and Kings College Hospital.
For the patient population, the availability of a service
which can provide acute care safely at home will
ensure the highest quality care, centred on best
practice and clinical outcomes and supports reducing
any negative impact of a hospital admissions or
prolonged hospital stay.
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2. Evidence base
2.1
What qualitative and quantitative
information and evidence would
enable you to makes the best
assessment and what do they say
regarding equality?
(consider health needs
assessments, public health input,
research, consultations,
stakeholders, local and national
reports etc)
A financial risk assessment has been completed
recognising the efficiencies and implications for
Community Services and Acute partners in GST The
financial risks have been shared in this document.
An analysis of the workforce implications has been
completed and will be discussed with HR and all
stakeholders.
An evaluation of the pilot schemes was undertaken last
summer, to include feedback from patients who had
accessed the service, GPs, acute colleagues in both
GSTT and KCH, social care in both boroughs and
community staff.
The business case has drawn on the literature.
2.2
If there are gaps in the evidence
how will this be generated?
Through consultation with staff, commissioners and
other stakeholders. The Home ward will form part of
the SLIC evaluation.
2.3
Does the evidence show that there
are different population groups
who have different needs or who
are suffering inequality (i.e.
consider health inequalities, poorer
progression for staff, difficulties in
retaining certain staff, differing
experiences of the service etc)
across the strands
The service will standardise the care pathways to
minimise any inequality that presently exists.
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2.4
Internal Involvement and
Consultation:
(e.g. with Departments, Staff
(including support groups),
academic partners, local
authorities)
Does this initiative affect the
experiences of staff? How? What
are their concerns?
How have you consulted, engaged
and involved internal stakeholders
in considering the impact of this
proposal on other public policies
and services?
What forms of consultation,
engagement and involvement have
been most effective?
Confidential
The proposals in this document have been drawn up
based on discussions and external evaluation of the
pilot which included users, and with a wide range of
stake holders ie commissioner, clinical staff , multidisciplinary teams across GST across the wider KHP
and Social Services and takes account of consultation
with voluntary agencies and user undertaken as part of
Southwark, Lambeth Integrated Care (SLIC).
We are proposing as part of a staff consultation to hold
information events where staff can come and hear
what is being proposed and ask questions, make
suggestions or seek clarification from managers.
Individual and small group discussions gathering views
on the Pilot service and inviting suggestions for the
scope and mode of operation of the implementation of
the service and presentations on the emerging
proposal where feedback has been invited.
What positive and adverse impacts
were identified by your internal
stakeholders?
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3. Assess the impact on equality and human rights
3.1
What opportunity is there to promote
equality of opportunity, good relations
or increase participation?
Although this will be a Community Service, it has
been co-designed with representation from
departments across KHP, commissioners and
Social Services, staff representatives and
participants of the Admission Avoidance
Programme Board. This has ensured that the
impact on services across the pathway has been
identified and addressed.
The model will create new posts which will
present opportunities for acute and community
staff.
3.2
What are the potential negative or
adverse effects?
There is potential for nursing staff in the existing
Pilot most of whom are seconded, or short term
contract to be put ‘at risk’ if they do not have the
competencies to manage the different patient
group and service intensity.
All affected staff members will be supported to
find alternative employment if required.
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3.3
Confidential
What is the potential for negative or
adverse effects assess
likelihood (1 = unlikely, 5 = certain)
3
severity (1 = very mild, 5 = very severe/
risk of death)
2
numbers of people affected (1 = very
few, 5 = almost everyone)
2
3.4
Is there public concern about possible
discrimination/ unfairness/ inequality?
3.5
How much evidence is there to
support these conclusions?
1 = none
No. The model has been developed to address
inequality in the present service which has only
been available to a limited resident population
related to certain GP practices..
4
2 = little
3 = some
4 = substantial
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3.6
What ability do we have to;
1.
2.
Alleviate or change unfair,
adverse or discriminatory
effects?
Promote and enhance positive
effects
Confidential
Negative effects from this service extension will
be minimised by consulting with all staff and
stakeholders and by ensuring all staff are in
suitable employment as far as possible by the end
of the process.
All issues and feedback staff raise will be
coordinated and forwarded to the relevant
manager or Lead to address and will form part of
any amended proposal.
Human Rights
3.7
Could the policy or function affect an
individual’s human rights?
No known impact.
Consider specifically the articles below
of the Human Rights act (1998):
Article 2 – Right to life
Article 3 – Right not to be tortured or
treated in an inhumane/degrading way
Article 5 – Right to liberty
Article 7 – Right to no punishment
without law
Article 9 – Right to respect for private
and family life and correspondence
3.8
What steps can be taken to negate
this?
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4. Screening assessment and next steps
4.1
Give an overview of the action that
needs to be taken now?
Completion of staff consultation
Analysis of feedback and modifications of
proposals
Agreement of final proposals
Implementation
4.2 Complete an action plan to highlight the next steps that need to be taken
Action
Responsibility
Timescale
Staff consultation begins
General Manager/
Workforce
TBC
Ensure all staff and their managers
have access to all relevant
documentation and information to
ensure full access to the
consultation and to enable
informed feedback
General Manager/
Workforce
From first day of consultation
through GTi and email. Ensure
printed copies on sites, available for
staff, as appropriate
Analysis of feedback and proposal
amendments
General Manager/
Workforce
Following closure of consultation
Agreement of final proposals
Community Senior
Management Team
TBC
Implementation of proposals
General Manager
TBC
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4.3
Does the screening show that there could be
differential or adverse effects on different
population groups?
No. This is a substantive service
following a Pilot which will address
any inequality in present care
pathways.
4.4
Is this policy or function a lawful positive action
initiative?
Yes
4.5
If a full EEIA is not required, please summarise your
reasons
Any staff or post put at risk knows
they have been involved in a Pilot
service and will be employed in an
alternative setting, most likely back
to their substantive roles.
Assurance
Name of lead
General Manager, Adult
Community Services
Lead director
Angela Dawe, Director of
Operations, Community Services
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Appendix 7
COST ESTIMATES FOR IMPLEMENTATION OF HOME WARD
HOME WARD NON-RECURRENT/SET UP COSTS
(estimates)
Accommodation adaptations
Office Furniture f and f
Medical and nursing equipment (inc VAT)
Site Costs (for set up )
IT and telecommunication contingency
IT - Laptops / Tablets and mobiles
Office equipment, inc PCs, printers, scanners, fax
Recruitment costs for Phase 1 set up
Training and development Phase 1 set up
Patient Monitoring (Telecare)
Uniforms
Ready use store set up
Total non-recurrent/set-up costs
HW Final draft AAPB 13.06.13
Total £
50,000
25,000
79,090
21,245
30,000
36,000
50,350
25,000
20,000
100,000
20,000
30,000
486,685
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Appendix 8
OVERALL IMPACT OF THE HOME WARD PHARMACIST
(Paper by Celia Osuagwu, Home Ward Pharmacist, Guy’s and St Thomas’ NHS Foundation Trust)
The Home Ward (HW) Pharmacist is a 0.5 WTE post that was recruited to in June 2012. The post
holder splits 2.5 days a week between Lambeth and Southwark sites, but is always contactable via
mobile phone and email during office hours. The involvement of a pharmacist has had a positive
influence on the HW Service from the perspective of the staff as well as patients.
Overall aims of post:
Develop and deliver a clinical pharmacy service to the Home Ward Team.
This includes providing advice and support to optimise the use of medicines by the team, as well as
leading on the medicines management aspects of patient care to reduce medicines related risk and
improve outcomes.
Main aspects of the Home Ward Pharmacist role:
1. Domiciliary medication reviews
2. Provision of clinical advice and support
3. Collating and analysis of prescribing data and information
4. Leading on the development of safe and effective prescribing guidance as well as medicines
handling processes.
5. Developing partnerships and facilitating collaborative working between multidisciplinary teams
and other agencies to improve medicines optimisation
6. Identifying and providing support to meet medicines management training needs for clinical and
non-clinical staff
A referral form was developed to enable HW staff to identify and refer patients to the pharmacist
(i.e. those who were deemed to be at the highest risk of medicines related morbidity and/or hospital
readmission and needed pharmacy input). The pharmacist screened the referral forms to enable the
prioritisation of workload. Patients deemed as high risk were visited at home. A structured ‘In-Depth
Medicines Assessment Tool’ was used to complete a holistic review of all aspects of medicines for
that individual. To date, the HW pharmacist has undertaken 30 In-Depth Medicines Reviews. 170
medicines related problems (MRPs) that patients were experiencing were detected, and
interventions were made by the pharmacist to resolve these issues. The MRPs have been separated
into access (e.g. problems with getting hold of medicines supplies), adherence (e.g. problems relating
to taking the medicines) and clinical issues (e.g. problems with side effects and monitoring).
Each MRP identified was rated using the NPSA risk matrix 1 and given a Red-Amber-Green (RAG)
value depending on the severity of the associated risk as follows:
(Risk score = consequence × likelihood)
Red = extreme risk
Orange = high risk
Yellow = moderate risk
Green = low risk
1
NPSA: Risk matrix for risk managers, January 2008
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Each pharmacist intervention was also rated using the RIO scoring system2 to capture the
likelihood of having avoided a hospital admission as follows:
1 – Unlikely to prevent a hospital admission
2 – Possibly may prevent a hospital admission
3 – Likely to prevent a hospital admission
Table 1: Summary of the MRPs identified and the Pharmacist interventions made
Access
Adherence
Clinical
Total
NPSA RAG rating:
Green
Yellow
Orange
Red
0
10
7
17
3
43
61
106
0
5
11
17
0
7
23
30
Total
MRPs
3
65
102
170
RIO score:
1
2
3
1
24
39
64
0
11
15
26
2
30
48
80
Total RIO
3
65
102
170
Table 2: Examples of interventions
Problem identified
Patient had been
taking colchicine
tablets for 2
months as opposed
to 6 days.
Patient was using
two blister packs at
the same time.
Intervention
made
Informed GP;
asked for
colchicine tablets
to be stopped.
Consequence
Likelihood
RiO Score
RAG
Category
Major
Possible
3
Orange
Safety issue
Pharmacist asked
the community
pharmacy to
move from
monthly to
weekly medicines
delivery so that
the patient only
has access to one
blister pack at a
time.
Moderate
Possible
2
Orange
Compliance
aid issue
Quarterly analysis of prescribing data is carried out to identify prescribing and cost trends. This data
is used to provide feedback to commissioners, and also to provide feedback to individual prescribers.
The data obtained has enabled the detection of issues around the supply of medicines at the point of
patient transfer from hospital. (Sometimes patients were discharged without appropriate quantities
of medication.) Identification of this issue has lead to a positive change in practice.
The HW Pharmacist has also been responsible for liaising with various stakeholders (e.g. Consultant
Microbiologist, Hospital Antibiotics Pharmacist, Home Ward GP, PCT pharmacists etc) to get
agreement for an intravenous antibiotics guideline that is fit for purpose for the HW service and the
types of patients that are treated. The guideline is currently awaiting the last phase before complete
approval3.
2
Adapted from the NHS Croydon RIO scoring system
3 Intravenous Antibiotics Guideline for Commonly Treated Infections in Patients Admitted to the Home Ward
Service in Lambeth and Southwark
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In addition to this, the HW pharmacist has also facilitated the process of obtaining emergency stock
items by liaising with Pharmacy stores at Guy’s Hospital so that treatment for patients can be
initiated in a timely manner, and admission can be avoided.
CASE STUDY: Mrs B:

Referred by social services (re: issues relating to medicines management).

Mrs B is a frail 85 year old lady with lots of co-morbidities including dementia, asthma, and
insulin dependent diabetes who is unable to manage the day to day aspects of taking her
medicines independently.

Mrs B’s husband is a frail 88 year old gentleman and is his wife’s main carer. He provides
support with the administration of his wife’s medicines. He himself has a variety of issues
surrounding polypharmacy4 and adherence to his own medicines regime. He is also partially
blind.
Key MRPs identified following HW pharmacist domiciliary medication review:

Polypharmacy (including long term Phenytoin5 (over 5 years) with no apparent indication)

Shortness of breath on exertion due to running out of reliever inhaler 3 years ago and this
item was never represcribed (and GP unaware of the problem).

Expired reliever inhalers found in cupboard in the midst of so many other expired
medicines

Mrs B’s husband had been applying cream to his wife’s leg that had expired over 3 years
ago. As he had poor eyesight, he was unaware that the cream had expired.
Actions:

Liaised with GP to review the need for ongoing Phenytoin.

All expired medicines were removed with the consent of the patient

Mrs B’s husband was educated on how to dispose of unwanted medicines appropriately
and was advised to make use of magnifying glasses to identify expired medicines in the
future

Asked GP to represcribe reliever inhaler.

Counselled Mrs B and her husband on how and when to use the reliever inhaler.
Outcomes:

Thank you letter received from the GP

Phenytoin gradually withdrawn and stopped as no indication

All information given to the District Nurses as they were taking over Mrs B’s long term care.
SUMMARY:
The HW Pharmacist has made a significant impact in the overall quality of care that the Home Ward
patients have received, and has also had a positive effect on the overall medicines management of
the Home Ward Service.
Celia Osuagwu, Home Ward Pharmacist, Guy’s and St Thomas’ NHS Foundation Trust
21st March 2013
4 Polypharmacy has various definitions. In this case it is defined as the concurrent use of four or more drugs in
a patient
5 Phenytoin is usually prescribed to treat epilepsy and is generally initiated by a Consultant Neurologist.
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Appendix 9
REFERENCES AND BIBLIOGRAPHY
Caplan G A,Ward J A Brennan, N J, Conconis, Board N, Brown A, Hospital in the
Home: a randomised controlled trial. 1999: 170: 156-60
Evaluation of two South London schemes: Home Ward and Enhanced Rapid
Response. 28 September 2012. Virginia Morley Associates (20 refs)
Jeppesen E, Brurberg KG, Vist GE, Wedzicha JA, Wright JJ, Greenstone M, et al.
Hospital at home for acute exacerbations of chronic obstructive pulmonary
disease. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.:
CD003573.
Leff B, Burton L et al, Comparison of Stress Experienced by Family Members of
Patients Treated at Home with that of those receiving Traditional Acute Care,
JAGS 56:117-123, 2008
Munton Tony, Martin Alison, Marrero Isaac, Llewellyn, Gibson Kate, Gomershall
Alan, ‘Getting Out of Hospital?’ – The evidence for shifting acute inpatient and
day case services from hospital into the community. (2011) The Health
Foundation, June (49 Refs)
NHS Institute for Innovation and Improvement; Delivering Quality and Value Directory of Ambulatory Emergency Care for Adults. Version 2 March 2010
The Queen’s Nursing Institute. 2020 Vision – Focusing on the future of District
Nursing, (2012).
Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, et al. Hospital at
home early discharge. Cochrane Database of Systematic Reviews 2009, Issue 1.
Art. No.: CD000356.3
Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Kalra L, et al. Hospital at
home admission avoidance. Cochrane Database of Systematic Reviews 2008,
Issue 4. Art. No.: CD007491.
Shepperd, S., Doll, H., Angus, RM., Iliffe, S., Kalra L., Ricauda, NA. and Wilson,
AD. (2008) ‘Admission avoidance hospital at home (Review), The Cochrane
Database of Systematic Reviews 2009, Issue 4. Art. No.: CD007491.
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