Virtual Ward incorporating Care Co-ordination, Person Centred Care Planning and Ok To Stay Planning

What we wanted to achieve? Primary Aim Achieve closer integration of Health and Social Care Services in order to improve outcomes for our patients by overcoming the fragmentation of care and to make a positive difference to the co-ordinated care they receive. Ensuring a fully holistic approach is utilised to provide the best possible outcome with the patient firmly at the centre.

Purpose of this way of working? To provide holistic proactive patient care and reduce the level of hospital admissions for our most vulnerable patients. The model aims to reduce duplication and improve continuity preventing/reducing unplanned admissions. It aims to integrate all elements of their care, utilising health, social and voluntary services increasing the their choices and ultimately empowering them to self manage. To act on evidence-based forecasts using a range of available data and local intelligence in order to reduce non-elective secondary care (acute hospital) usage. Mel can this have a few pictures in it What about the house of care?

Findings from the pilot The non-elective activity (age 65+ only) volume for Dovercourt practice was compared to the 2015/16 activity. The data showed a saving profile of around 3 admissions per week (14% reduction) during the running of the pilot (primarily winter months).

The graph below shows Dovercourt Practice level of non-elective admissions for 65+ age group from 2014/15 to 2016/17. The pilot commenced in week 27 of 2016/17, the green line is fairly consistently below previous years’ activity levels.

How does it work?.........

STH Discharge Email DN team have been receiving this daily email Pings through @ 06.30 every morning or weekly for some surgeries. Helps nurses co-ordinate caseload daily and cancel visit if they are in hospital, decreases the level of no access visits and also the clinical time it take locating these patients. Informs team when a patient is discharged as we all know we are not always informed by the referral process if they are considered to have no DN need by the ward but we manage their LTC or they leaking legs once they are home and no longer in bed like they were in hospital

Daily Email From GP Surgery Courtesy of Jayne Peat Dovercourt took this email one step further and Jayne peat their admin transfers the data to this format. These emails are sent daily to GPs nurses and have been for a few years The hospital emails do not come in this format, an admin worker organises these daily so that we are able to view them in a user friendly way It has been extremely useful to know who is in hospital as it can enable us to know if we do not need to visit (if a patient is has been admitted) While it was useful to have this data, the surgery we did not have the resources to pull is together to co-ordinate working a ‘virtual ward’ (which the surgery has always wanted)…..(you could talk about the failure of the croydon model here.) The DN and CM ‘co-ordinate’ care but cannot possibly be at the dash board overseeing the whole picture. This would take our clinical face to face time away, we cannot afford that.

What makes this Virtual Ward different? Central Co-ordinator Joanne Watson Evidence has shown that without a central co-ordinator previous virtual ward models have reverted back to previous way of working once the pilot stage ends Lewis et al (2013) Central Co-ordinator

192 Patients Managed In The VW How We Decided Who Would Be On The Ward How We Red Amber Green Rated Them (Rag Rating) Managed By The VW Co-ordinator Developed A Model of RAG Rating And A Live Spreadsheet Using: Frailty Index Risk Statification Tool Emails From Secondary Care (All Non Electives Went Onto Red for MDT Discussion) Unplanned GP Visits Local Knowledge of Staff Case Study (Long LOS On Red) 53 From October 2016 To February 2017 192 Patients Managed In The VW 101 100

Person Centred Care Plan or Ok To Stay Plan So which plan?

Colin’s Hospital Timeline A+E Attendances Hospital Admissions Out Patient Prior To OK to Stay Plan From January To April 7 Admissions Resulting In 35 Days Since Then 1 A&E Attendance And 1 Recent 3 Day Admission Out Patient Appointments Attended To Ensure Appropriate Primary And Secondary Care Interventions and Collaboration Niks bit

Case Study Who helped us write the plan? Patients GPs ICE Information From Consultants Specialist Nurses Other Professionals (HCA play an important role) Now Age UK, Community Support Workers

Professionals Involved GPs including OOH GPs GP and DN Admin Service Co-ordinator Paramedics District Nursing Team (all bands) SPA Phlebotomy Active Recovery SALT Age UK Respiratory Physiotherapist St Lukes Outreach Team Telehealth Pharmacist Oxygen Service Consultants Equipment Services Ambulance Service OP Diagnostics

Identifying patient with an OK to Stay Plan This Is Colins Back Door Lots Of Promotional Materials Available Alerting Everyone That There Is A Plan On Colin’s Last Admission The Paramedics Took His Ok To Stay To Hospital ? Print 2 Just In Case A patient Is Not Ok To Stay - Imagine The Value Of This Information In The Hospital… A great example of this is that Colin only had a three day stay. We believe this is due to the information on his ‘OK to Stay’ Also the trust developed with the COPD hospital team who know how we work in the neighbourhood.

Thank You To Colin For Sharing His Story Any Questions?