1. Hull Intermediate Care Service Service Development Carol Crone / Jim Deacon May 2003

2. Team Information Nurses,Therapists,Social Care Staff Referrals are from all health and social care departments One main office base,one acute hospital base Patients seen at home, also residential placements and nursing home beds Team operates 24 hours/day 365 days/year

3. Easing Bed Pressure Red alert last winter Acute and Community Managers want to work together to make a difference. (history of good relationship) Immediate work required

4. Transfer of Care Team Intermediate Care Mini-Team @ hospital Ward staff asked to complete a daily return of patients medically fit but for some reason could not leave the ward.

5. Reasons for not leaving Awaiting OT report Waiting for aids/adaptations Waiting for services to start Need observation A bit unsteady Need a blood test …….etc…….

6. The Busy Ward Staff looking after poorly patients Complex access to Community Services Initial reluctance re more forms to fill in (daily returns)

7. I.C.Team Daily returns to identify patients to pull through Team able to focus on the discharge pathway.(not involved in other ward pressures) Process may take time with some patients - others very quick

8. I.C. Team (2) Team aware of Community Services Team able to directly access Int.Care immediately

9. Dedicated Community Ward Ward commissioned in Hull (in a nursing home) GP responsible for ongoing care Consultant from Acute Trust oversees Nursing Care from nursing home Part of IC Team -facilitates home follow up if further rehab. needed

10. Team Commitment Team flexible to meet need Acute and Community see as one responsibility Team in position to inform Commissioners

11. Negatives React to Crisis Patients approached late (not part of admission and care pathway) Several patient moves Some clinicians not keen on patients leaving hospital system

12. Positives Patients had more choice Raised profile of I.Care in Acute setting Improved Communication Revolving door patients reduced Reduced trolley waits / Increased capacity Reduced risk of hospital aquired infection

13. The Future This summer Develop specific Care Pathways through the hospital Consent document that addresses patient awareness re. rehab /nursing home placements etc

14. The Future (2) Improve sit reps. Build upon current good relationships to Increase the team including Social Services Simplify the discharge procedure - straightforward community profiles

15. Hull Intermediate Care Team Developing Services Carol Crone / Jim Deacon May 2003