stephanie_lawrence by lanyuehua


									Airedale Collaborative Care Team

         Steph Lawrence Team Leader 6/12/11
Why did we do it?

Community services
 8 social services rehab beds for 140,000 people
Small rapid response team
No capacity in community services to support at home
Acute trust
Increased length of stay
Delayed discharges
Intermediate care beds in the acute hospital
What did this mean?
• In acute hospital setting after medically fit for discharge
• Secondary problems developing
• Medical model care not close to home

• Increasing numbers of A&E attendances, and hospital
• No way of reducing acute demand because of
  community alternatives
• No buildings for cost effective beds
Strategy development
• Multi-agency service specification developed by GP Alliance
• One vision consistent with principles of Intermediate Care
• Consulted with two main providers and GPs
• Re-scoped to focus on step up and step down services
• Aim to reduce admissions and length of stay
• Pump prime a multi-disciplinary team
• Contract community beds in the independent sector
• Develop ‘virtual’ beds in patients own homes
• Decommission intermediate care beds in the acute setting.
              Strategy Implementation

                       Directors group

                     ACCT Steering group

                   ACCT Operational Group
 Secondary Care                                Primary Care
     Teams                                        Teams
•Case managers                              •District nurses
•Ward staff                  ACCT           •Community matrons
•Therapists                  Team           •Specialist nurses
•Social workers                             •Social workers
                        Patient Pathways
•Matrons                                    •Therapists
ACCT Launch
• Engagement with all stakeholders at all levels
• Cross professional/organisation led to demonstrate the
• Patient scenario focussed (theatre group)
• All stakeholders encouraged to ask questions and raise
• Action plan developed to address issues during service
Multi Disciplinary Team Working
• No one professional can provide all that our patients require, it takes
  team work and commitment
• No one professional is more important than another BUT our
  patients are very important
• Multi-disciplinary team working within ACCT encompasses;
  Physiotherapy, Occupational Therapy, Mental Health specialist,
  Doctors, Nurses including Advanced Nurse Practitioners, Rehab
  and Health Care Support Workers, Social Worker, carers Resource
  worker and the wider primary and acute care teams are our virtual
• A shared clinical record is essential for true multi-disciplinary
• April 2010 – March 2011 1190 patients
• 180 patients through the care home beds
• 1010 patients in there own homes
• 60% discharged home without care package
• 30% discharged home with ongoing support
• 7% re-admitted to hospital
• 3% admitted to long term care
Patient Feedback
• Goal planning and patient/relatives involvement
• Shared governance structure across all organisations and
  professions ensures shared learning
• Some patient quotes:

• I was so glad to be out of hospital. I have improved well at home.
• Felt team gave confidence and felt comfortable with all the team
• I was made to feel confident to manage on my own with the
  excellent care I was given – this is an invaluable service
Success Factors
• A common vision which includes blurred boundary working crucial to
  delivery of care and leads to efficiency and value for money
• Leadership and commitment from all partner agencies
• Drive and enthusiasm from frontline staff
• Innovation and drive from the senior clinical team
• Single management structure
• Impact on other services and development of care pathways
• Benefits to patients e.g. Community Matron quote
What ACCT means to one Community Matron
•  The Airedale collaborative care team has provided a valuable service to myself working as a community matron, to
   the GP practice as a whole and most definitely to my patients. They act as a close link between primary and
   secondary care and are in a true sense a multi-disciplinary team, which is often necessary for our elderly patients
   with multi-factorial disease. In addition to the nursing aspects, the access to the other therapists including a mental
   health practitioner is fantastic.
•  By providing 24 hour support and care the Acct team have been instrumental in helping to avoid patients being
   admitted to hospital. They enable patients to be cared for at home during periods of acute illness/ exacerbations of
   chronic disease. The fast speed of initiating more comprehensive care means that these patients can remain at
   home when otherwise they may have been admitted to hospital.
•   The Acct team also facilitate early discharge and assist with discharge from Accident and Emergency. In addition
   as a community matron I have access to intermediate step -up beds which have proved beneficial for some elderly
   patients who required a more intense level of care but may not necessarily require acute secondary care
•  The Acct team give good quality, holistic care for which I can't praise them enough, they are thorough, hard
   working and provide peace of mind for myself that my patients are cared for and are safe in their hands.
•  Jane Giles Community Matron
      Transforming Community Services
“Encouraging integration between providers is the most rational way
     forward to reduce fragmented care, the avoidable ill health it
                 produces, and to improve efficiency”
   Judith Smith Nuffield Head of Policy (HSJ 2 September 2010)

                 Airedale Collaborative Care Team
                     is making progress against
                         all three outcomes
                        The Future

•New investment from re-ablement monies
•Expansion of the team especially social care and voluntary sector
•Increase in bed base
•New pathways in development
•Further integration with social care including home care intake
•Further integration with voluntary sector
•Integrated pathways with acute trust
•Exploring joint IT systems to develop integrated electronic patient record
•More care closer to home for patients
•Patient at the centre of what we do – nothing about me without me

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