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Outlier for emergency admissions Care of frail elderly and patients with complex needs reactive and uncoordinated Figures 07-08: SAR all ages 107 SAR Readmissions within 28 days: all ages 10%; % Hardwick Clinical Commissioning Group 2

Visited Croydon to look at their Virtual Ward model Aware of Unique care model introduced at Shires Wanted to build on the good work CM already doing Work in a more integrated way with DN team and Acute care Hardwick Clinical Commissioning Group 3

Embedded in Primary Care Adopted principles of Unique Care: case management; integrated working with SS and joint assessments CM lead professional Close working ICS, SN, Palliative care Hardwick Clinical Commissioning Group 4

Care co-ordinator as Ward administrator Integrated working with DN team GP Champion VW Process Flow Chart Patient Leaflet Practice Leaflet Hardwick Clinical Commissioning Group 5

Mr B. 79yr old man with COPD, Bladder Cancer, Pernicious Anaemia, Pneumoconiosis Home visit because of swollen ankles, increasing SOB, declining mobility. LTOT but sats only 78% on air increasing to 85% on 4L O2. Impn Cor Pulmonale. F/U with Home Oxygen Team chased. Commenced on Furosemide and increased ventolin dose. Referred for ECHO and to VW as assessed to have complex needs and to be at risk of admission S/B CM and SW on joint visit – paper work and appt arranged by CC 6 Hardwick Clinical Commissioning Group

Clinical care under review by CM. Support from SS declined at the moment but SW now familiar with situation so when deteriorates can organise support quickly. When seen by Steve Collis for O2 assessment unwell and sats not recovering. Organised admission. In hospital over night and advised that there was nothing else that they could do for him. CM has had several visits to the house over the last 2-3w. Has discussed preferred place of care/DNAR etc. Rightcare completed. Will review ECHO when available and liaise with GPs re future management. DNs aware of the situation as will be involved in EoL care. 7 Hardwick Clinical Commissioning Group

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Joint working with SS – mutual learning experience. Access to each others records invaluable. In reach into Acute Care – Matron to Matron discussion. Supported by joint matron forum. Rightcare Improved EOL/Advanced care planning Hardwick Clinical Commissioning Group 9

Joint working with DN team Care co-ordinator – co-ordinates intelligence and maintains board with list patients in hospital Evaluation demonstrated excellent patient and staff satisfaction. Bucked the trend for emergency admissions for Derbyshire Hardwick Clinical Commissioning Group 10

Everyday tasks have been much easier Nice to be able to talk about Dads medical problems Peace of mind for the family I have a more positive attitude I know that help is near if required The service provided is first class Its easier by not having to get to the doctors or go into hospital 11 Hardwick Clinical Commissioning Group

It has had the following influence on my work:- Better understanding of complex care management Improved ease of accessing appropriate medical and social support for patients with complex needs Tracking patients is useful Improved continuity of care 12 Hardwick Clinical Commissioning Group

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Consider rolling out the model across all practices – model modified to specific area Build on current in reach work to achieve full Integrated care – e.g. Matron Forum Facilitate early discharge from Acute Care Expand specialist support in the community e.g. Community Geriatrician, Support Worker for Dementia Hardwick Clinical Commissioning Group 17