Community Health Services for North Somerset. Bidder Information Pack (ITN 1)

Transcription

1 Community Health Services for North Somerset Bidder Information Pack (ITN 1)

2 Contents Section 1: High level service outcomes... 6 Introduction... 7 Sources... 7 National outcomes... 8 NHS Outcomes domains:... 8 Adult Social Care Outcomes domains:... 8 Public Health Outcomes domains:... 8 Healthy Child Programme - Pregnancy and the first five years of life... 8 Healthy Child Programme from 5 to Note on the 2014 Care Act... 9 Definitions... 9 Domain types Outcomes and indicators Overarching domain A: Ensure people have an excellent and equitable experience of care and support with care organised around the individual Overarching domain B: Treat and care for people in a safe environment and protect them from avoidable harm Overarching domain C: Develop an organisational culture of care centred on the individual, joined up working, empowering staff and effective information sharing Pathway domain 1: Health promotion and education, and prevention of illness Pathway domain 2: Early interventions to promote wellbeing and independence Pathway domain 3: Treatment and/or support during an acute episode of ill health Pathway domain 4: Long term recovery and sustainability of health Pathway domain 5: Care and support for people at the end of their lives, for both cancer and non-cancer diagnoses Page 2 of 64 September 2014

3 Section 2: Summary of current services Introduction Admission Prevent Team New service under development Advice and guidance service Bladder and Bowel service Case Coordination of intensive rehabilitation for brain injured patients Clevedon Community Hospital (CCH) inpatients Clevedon Community Hospital Minor Injuries Unit Community Advanced Nurse Practitioner (2 year pilot to March 2016) Community Heart Failure Service Pilot for 2 years end date July Community Home Oxygen Assessment Service Community In-Reach Team (CIRT) Community Intravenous Antibiotic Service Community Neuro Team Community Podiatry Services Community Pulmonary Rehabilitation Community Rapid Response Team Out of Hours Nursing (OOH) Community Teams Community Team for People with Learning Disabilities (CTPLD) Community Team for People with Learning Disabilities Intensive Support Team (IST) Diabetes Specialist Nursing Service (Adult service) Diabetes Specialist Nursing Service (Paediatric) Enablement Support Service End of Life Care Coordination Service Falls Prevention and Management Service Page 3 of 64 September 2014

4 Funded Healthcare and Continuing Health Care Team (FNC/CHC) Health Professionals within the Professional Assessment Team (PAT) based in the Single Point of Access (SPA) Health visitors Integrated Care Teams Lymphoedema service (North Somerset, South Gloucestershire and Bristol ) Mental Health Placement service Musculoskeletal Interface and Physiotherapy service No Worries and No Worries Parkinson s Disease Specialist Nurse 2 year pilot ends July Residential home support service Respite service (Orchard View Only) School Aged Immunisation Service School Nursing Service Specialist Older People Team New Service under development Tissue Viability Service Weekend Wound Care Clinic Section 3: Summary of current service delivery locations Principles of service location Services currently delivered in patient s home/nursing home/residential home Services currently delivered in community settings Services currently delivered in an acute setting Current referral and co-ordination services Section 4: Summary of opportunity services (as referenced in ITN 1 Question 8) Introduction Better Care Fund (BCF) Page 4 of 64 September 2014

5 Planned Care Prevention and wellbeing Primary Care Section 5: Current services indicative projected annual activity level estimates for Introduction Indicative activity Page 5 of 64 September 2014

6 Section 1: High level service outcomes Page 6 of 64 September 2014

7 Introduction This document outlines the overarching high-level outcomes and indicators for Community Services in North Somerset in order to provide bidders with the information required to develop outline service models for the initial stage of negotiation. Service-level outcomes will be released at the second negotiation stage. Sources The outcomes have been developed from the following sources: Stakeholder involvement groups, including service users, carers and GPs The Advisory Group evidence evaluation exercise, June 2014 The North Somerset CCG 5 year Strategic Plan 2014 The NHS Outcomes Framework 2014/15 The Adult Social Care Outcomes Framework 2014/15 The Public Health Outcomes Framework 2013 to 2016 Healthy Child Programme - Pregnancy and the first five years of life NHS England; Healthy Child Programme 5 to 19 Safe, compassionate care for frail older people using an integrated care pathway, February 2014 British Geriatric Society Silver Book : Quality Care for Older People with Urgent Emergency Care Needs Page 7 of 64 September 2014

8 National outcomes We would expect any integrated service to contribute to the achievement of the following outcomes frameworks. Please note that these are subject to changes following the national annual review. NHS Outcomes domains: 1. Preventing people from dying prematurely 2. Enhancing quality of life for people with long term conditions 3. Helping people to recover from episodes of ill health or following injury 4. Ensuring that people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm Adult Social Care Outcomes domains: 1. Enhancing quality of life for people with care and support needs 2. Delaying and reducing the need for care and support 3. Ensuring that people have a positive experience of care and support 4. Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harm Public Health Outcomes domains: 1. Improving the wider determinants of health 2. Health improvement 3. Health protection 4. Healthcare, public health and preventing premature mortality Healthy Child Programme - Pregnancy and the first five years of life 1. Care that helps to keep children healthy and safe 2. Healthy eating and increased activity, leading to a reduction in obesity 3. Prevention of some serious and communicable diseases 4. Increased rates of initiation and continuation of breastfeeding 5. Readiness for school and improved learning 6. Early recognition of growth disorders and risk factors for obesity 7. Early detection of, and action to address, developmental delay, abnormalities and ill health, and concerns about safety 8. Identification of factors that could influence health and wellbeing in families 9. Better short and long-term outcomes for children who are at risk of social exclusion. Page 8 of 64 September 2014

9 Healthy Child Programme from 5 to Prevention and early intervention; (unintentional and deliberate injuries in children) 2. Key health priorities; (health inequalities, emotional health, promoting healthy weight, long standing illness or disability, teenage pregnancy and sexual health; drugs, alcohol and tobacco; ) 3. Safeguarding; 4. Health development reviews at key transition points (Reception, Year 6, mid teens) 5. Screening and immunisation programmes; 6. Signposting of services; 7. Environments that promote health (all schools, all FE settings, age appropriate PSHE, You re Welcome quality standards) 8. Support for parents and carers (particular focus on parents/carers who have children with additional health needs) 9. School attendance Note on the 2014 Care Act North Somerset Council adult social care is in the process of implementing the 2014 Care Act, the terms of which come into full effect in April While the finalised guidance has not yet been published at the time of writing, the stated outcomes as indicated in this document do reflect the overall principals outlined by the Care Act. It should be noted, that this is a significant change in legislation for adult social care, and may affect both the terminology and emphasis of stated social care outcomes Definitions In this document, the term People includes adults of working age, older people, children and young people in North Somerset, as appropriate. For all outcomes, consideration of carers should be apparent. Page 9 of 64 September 2014

10 Domain types The outcomes for Community Services for North Somerset are of two types: Overarching domains which cross the entire care pathway, and Pathway domains which align to key stages of the care pathway A: Ensure people have an excellent and equitable experience of care and support with care organised around the individual. B: Treat and care for people in a safe environment and protect them from avoidable harm C: Develop an organisational culture of joined up working, patient centred care, empowering staff and effective information sharing 1. Health promotion and education, and prevention of illness 2. Early interventions to promote wellbeing and independence 3. Treatment and/or support during an acute episode of ill health 4. Long term recovery and sustainability of health 5. Care and support for people at the end of their lives, for both cancer and noncancer diagnoses Page 10 of 64 September 2014

11 Outcomes and indicators Overarching domain A: Ensure people have an excellent and equitable experience of care and support with care organised around the individual Outcomes (Overarching measures) A.1 People and carers have an overall excellent experience of care and support. A.2 People and carers experience effective joined-up working and coordinated care A.3 Patients and carers are empowered to lead the planning of their care in partnership with professionals A.4 Patients have access to information in an appropriate language and format, when they need it A.5 Patients have equitable access to a range of community services which meet their needs Overarching domain B: Treat and care for people in a safe environment and protect them from avoidable harm Outcomes (Overarching measures) B.1 Care is provided in a safe environment with robust safeguarding plans in place including staff training across the provider-led system plus audit for protecting vulnerable people from avoidable harm with responsive action plan B.2 Reduction in the number of adverse experiences for patients and carers B.3 Robust processes are in place to ensure learning from audits and reviews of patient care B.4 Robust systems and measures are in place to reduce pressure ulcers, healthcare acquired infections, falls and medicines related incidents Page 11 of 64 September 2014

12 Overarching domain C: Develop an organisational culture of care centred on the individual, joined up working, empowering staff and effective information sharing. Outcomes (Overarching measures) C.1 Staff and whole organisations are committed to working in a joined up and integrated way C.2 Staff are empowered to deliver excellent outcomes for individuals C.3 Authentic and collaborative leadership is evident across and within organisational boundaries C.4 There is an organisational culture characterised by high staff engagement which supports and facilitates a duty of candour and openness C.5 There is an organisational culture that supports staff to learn and improve Pathway domain 1: Health promotion and education, and prevention of illness Outcomes (Overarching measures) 1.1 The service supports delivery of the Healthy Child Programme - Pregnancy and the first five years of life 1.2 The service supports delivery of the Healthy Child Programme Improved sexual health of under 25 year olds 1.4 The service supports delivery of the national public health outcomes Page 12 of 64 September 2014

13 Pathway domain 2: Early interventions to promote wellbeing and independence Outcomes (Overarching measures) People with long term conditions experience improved stability and reduced complications (Patient reported outcome measure) All patients with a long term condition (under the care of community services) feel supported to self-manage their condition and maintain their independence (Patient reported experience measure) All people can access care, information and support which is timely, co-ordinated and recognises the importance of wider determinants of health (Links to A.4) People s health and independence is maintained or improved through proactive assessment, care planning and interventions 2.5 People experience improved mental health and wellbeing and quality of life through early support and diagnosis Pathway domain 3: Treatment and/or support during an acute episode of ill health Outcomes (Overarching measures) 3.1 The system supports a reduction in the number of days spent in hospital from emergency admissions The system supports a reduction in the number of days spent in hospital from emergency admissions by people with alcohol or drug related dependencies The service effectively works with primary care to manage acute health episodes of people with long term conditions, minimising unnecessary hospital admissions where medically appropriate 3.4 The service supports the timely discharge of medically fit patients by secondary care back into the community Page 13 of 64 September 2014

14 Pathway domain 4: Long term recovery and sustainability of health Outcomes (Overarching measures) People make a sustainable recovery after admission to acute or intermediate care, with a reduction in readmissions or complications People make a sustainable recovery after admission to acute or intermediate care, with no avoidable deterioration in health 4.3 People feel supported in the community following discharge and during their recovery period 4.4 Personalised packages of care are constructed, and treatment systems are responsive to people s needs Pathway domain 5: Care and support for people at the end of their lives, for both cancer and non-cancer diagnoses Outcomes (Overarching measures) 5.1 The quality of care experienced by the person who died, and their families, as reported by carers, was excellent 5.2 Specialist community palliative care services are available for those who require them in a timely manner 5.3 Staff are trained, enabled and supported to look after those who are dying in an appropriate and compassionate way 5.4 People are supported to develop personalised Advanced Care Plans, including DNAR conversations. 5.5 People achieve their preferred place of death Page 14 of 64 September 2014

15 Section 2: Summary of current services Page 15 of 64 September 2014

16 Introduction This is a list of current services delivered under the Community Contract, each of the descriptions identifies: A description of the service Integrated organisations. Please note that the community teams in the South of the patch are integrated with Social Care. By 2016 all teams will be integrated in the whole of North Somerset. Please note that during the negotiation they may be subject to change, and therefore the inclusion of these descriptions should be considered as a starting point for bids. Page 16 of 64 September 2014

17 Admission Prevent Team New service under development In summary the new model of care will: Support admission avoidance and discharge from the Emergency Department and Ambulatory Care Unit at Weston General Hospital, via an Admissions Avoidance Co-ordinator that will be available 7 days per week and will redirect patients to the most appropriate local community settings to avoid hospital admission and free capacity within the acute trust. Community Emergency response supporting both SWAST and Pendent providers such as Care link to support Fallers in the community with the aim of: o Reducing the number of unnecessary ambulance callouts to fallers in the community o Reduce the number of inappropriate transfers to hospital of fallers across the whole of North Somerset so affecting all main acute trusts that North Somerset patient are conveyed too. o Increased capacity in the community to provide a rapid response to patients when required. Providing seven day working for the community therapy service that can support community patients either in the community and aid system flow as demonstrated during the winter period 2013/14. Provide flexibility for the spot purchase of safehaven beds within the system when more intense support is required. Additional SPA clinical triage nurse capacity ensuring that patient and carers are directed and signposted to the most appropriate care or support in the community. Via Health Care Professionals Nurses, Therapists, Co-Coordinator, Generic Support Workers, Administration Support. 24/7 Integration with: Current provider only Page 17 of 64 September 2014

18 Advice and guidance service This is a service available to North Somerset GPs, to request additional input from a clinical colleague with specialist knowledge into determining the best care pathway for a patient Currently this is in a test and learn phase to determine suitable specialities for future roll-out. Advice only Advice is provided within in an agreed turnaround time. Clinical specialists Integration with Dependent on outcome of test and learn. Page 18 of 64 September 2014

19 Bladder and Bowel service The service provides the following: 1. To proactively treat, or facilitate the treatment of, children and adults in North Somerset that present with bladder and/ or bowel problems. 2. To provide a range of education and training to health and social care professions in the management of bladder and bowel conditions. 3. To oversee the management of the home delivery service contract for continence products. 4. Improve awareness that continence issues can be treated. The Service operates an open referral system anyone can refer into the service as long as they have the patients consent. Patients who self refer will initially be sent advice to follow. Appointments will then be offered if this is insufficient. Monday Friday 08:30 16:30 excluding Bank Holidays. Days and times of clinics vary according to demand. Clinical & Operational Lead, Specialist Nurses, Administrator Current provider only Page 19 of 64 September 2014

20 Case Coordination of intensive rehabilitation for brain injured patients To be responsible for managing the referral pathway for patients for whom specialist assessment is required in order to determine their rehabilitation pathway. To ensure patients receive specialist brain injury rehabilitation in accordance with their assessed need in the most appropriate environment To coordinate the care pathway for individual patients ensuring their smooth and timely transition along their rehabilitation journey To work with community and social care colleagues on securing step down placements from specialist rehabilitation and ongoing care needs for service users Referrals may be received from acute trusts and neurosurgical units. Patients over 18 years old only. Monday Friday, 9am 5pm excluding bank holidays Care Coordinator Integrated Current provider only Page 20 of 64 September 2014

21 Clevedon Community Hospital (CCH) inpatients CCH is an 18 bed community hospital. The key focus of the in- patient beds is to provide rehabilitation services for patients on agreed pathways from acute hospitals. In addition the hospital provides three GP- led beds to help avoid admission to /facilitate discharge from acute hospitals. A holistic, integrated and co-ordinated service will be provided to patients based on individual needs, as determined by comprehensive assessments. The service providers are responsible for ensuring a joined up approach to inpatient care and for discharge planning from the inpatient facility at CCH. All referrals into CCH are made via the site coordinator. Referrals may come from acute trusts, GPs, Community Teams and other Community Services. CCH provides 24 hour nursing care, 7 days a week and therapy 5 days a week The service is staffed by a multi-disciplinary team supported by a team of volunteers. The provider holds an SLA with Clevedon GPs to provide medical cover. Current provider only Page 21 of 64 September 2014

22 Clevedon Community Hospital Minor Injuries Unit A nurse led service providing triage, management and treatment for minor injuries and illnesses, healthcare advice, and health promotion. By personal attendance or telephone enquiry to the MIU. The service can be routinely accessed without appointment. Sources: Direct self-referral, GP, Ambulance Service, Community Services, 111, X-ray service 08:00 21:00, 365 days per year ENP/ECP, Practitioner, Administration Support Current provider only Page 22 of 64 September 2014

23 Community Advanced Nurse Practitioner (2 year pilot to March 2016) To provide a safe, robust clinical service based in the community, that tackles health inequalities by working with the most vulnerable groups in Weston-super-Mare including those who are socially excluded, homeless, and unemployed and/or have substance misuse problems. To reduce the number of adults in North Somerset who are not registered with a GP. To work with allied health professionals to be able to offer a whole range of services in health & social care and the voluntary sector to these individuals. Delivering care at the right time in the right place for the individual. The aim is to work in partnership with this group of individuals to empower them to self-manage their own health issues where appropriate. Provide appropriate interventions on a range of Public Health lifestyle issues including: weight management, healthy eating, increasing physical activity, reducing substance misuse, reducing alcohol (including alcohol screening and brief advice) and stop smoking. In addition, proactively encourage the uptake of and delivery of NHS Health Checks. Allied Health Professionals, OOH GPs, Self referral 09:00 17:00 Monday to Friday excluding Bank Holidays Advanced Nurse Practitioner Current provider and GP Practices Page 23 of 64 September 2014

24 Community Heart Failure Service Pilot for 2 years end date July 2015 To increase and improve the management of chronic heart failure in the community thereby reducing emergency admissions to acute care, reducing length of stay for unavoidable admissions and improving patient s ability to self care. This service is supported by the British Heart Foundation. Patients that have a diagnosis of heart failure confirmed by echocardiogram by a health care professional. 9am 5pm Monday to Friday, excluding bank holidays Community Home Oxygen Assessment Service Nurses, plus 3 sessions per month from Weston General Hospital Consultant Cardiologist. Current provider, British Heart Foundation and Weston General Hospital. The service is provided to assess and monitor a patient s need for oxygen therapy and to ensure that the patient s health and quality of life is maximised, any risk is minimised and that the right oxygen levels (including flow rates and duration) and equipment is provided to meet their clinical needs. Referrers to the service are health care professionals. Core hours are Monday to Friday, 8.30am 5pm excluding Bank holidays Specialist respiratory nurses and Administration support. Current provider only Page 24 of 64 September 2014

25 Community In-Reach Team (CIRT) Improved patient centred-care, moving through the acute health care system at optimal speed on clear patient discharge pathways Improved intelligence for Community Services staff re the status and progress of patients from their locality who are temporarily under the care of the acute trust Identification and facilitation of discharge of patients who are primarily over 75 years of age and; have conditions that tend to lead to a long length of stay or have a history of frequent re-admission to hospital An established and respected contact point for acute colleagues regarding North Somerset Community Partnership Earlier intelligence re potential escalation enabling pro-active rather than reactive management of patients Acute colleagues and Community Team staff 8:30 am to 4.30 pm Monday to Friday, excluding Bank Holidays. A small team comprising Community Nurses, Occupational Therapist and administrative support. Current provider only Page 25 of 64 September 2014

26 Community Intravenous Antibiotic Service The IV service provides IV antibiotics to people within their own homes, up to 3 times in a 24 hour period. To educate and support care homes and GPs to prevent emergency admissions to hospital Provide a safe alternative to hospital admission thus reducing hospital acquired infections. Enable intravenous antibiotic therapy to be delivered from community wards where appropriate Identify enhanced pathways for the provision of intravenous therapies within primary care. Referrals are accepted from healthcare professionals for all patients that require IV antibiotic treatment in their own homes. 8.30am to 10pm, 7 days a week Nurses and Administrative Support Current provider only Page 26 of 64 September 2014

27 Community Neuro Team This is a community based specialist service comprising a Multiple Sclerosis (MS) Specialist Nurse; Stroke Care Coordinator; Parkinson s Specialist Nurse occupational therapists; physiotherapists and speech and language therapist. The community neuro team provides a specialist, primarily neurological holistic and inter-disciplinary rehabilitation and resource service for adults in the community. Therapy - Anyone can refer themselves or someone else with the consent of the person being referred. MS Specialist Nurse - People with MS can refer themselves or be referred by anyone else Stroke Care Co-ordinator - Health, social care and independent sector professionals, with self-referral back to the service from previous service users. Parkinson s Specialist Nurse see separate service description. 08:30 17:00 Monday to Friday excluding Bank Holidays Multiple Sclerosis (MS) Specialist Nurses, Stroke Care Coordinators; occupational therapists; physiotherapists and speech and language therapists Current provider only Page 27 of 64 September 2014

28 Community Podiatry Services The Service provides treatment to people of all ages whose medical condition means their foot health is at risk, e.g. those who have peripheral vascular disease, neuropathy, diabetes or are immunocompromised. The provision of care can be of an acute as well as a chronic nature. Due to this fact, patients can be seen for a short term package of care or can have ongoing care for an indefinite period. The Service provides: Podiatric Medical assessment, diagnosis, treatment and health education to patients suffering from lower limb and foot pathologies, e.g., sharp/surgical debridement, ulcer care, minor surgery and biomechanical/orthotic therapy. An individual treatment plan and intervention with emphasis on self management. This can include exercises, foot care/wear advice and education on any other foot or lower limb related pathology. Education, advice and support for patients and carers A range of educational talks for staff and newly diagnosed patients with diabetes. Health care professionals Specialist Podiatrists, Senior community Podiatrists and community Podiatrists, Foot Care Assistants and administrative support staff. 8.30am 5pm, Monday to Friday (excluding bank holidays) Current provider Podiatry service provides an estimated 10 hours a week of podiatrist time to support WAHT clinics. Current provider only Page 28 of 64 September 2014

29 Community Pulmonary Rehabilitation The Service is for adult patients who require professional specialist respiratory intervention in a community setting. The programme includes an initial individual specialist assessment, six weeks of twice weekly supervised exercise sessions and disease education followed by individual post programme assessments. Respiratory Consultants, Respiratory Nurse Specialists, Community Teams, GPs, Practice Nurses and other Allied Health Professionals. Core hours are 9-5 Monday to Friday (excluding bank holidays) Programmes are usually delivered on two non-consecutive days a week. Specialist respiratory physiotherapists, Respiratory nurse specialists, Physiotherapy assistants, Guest speakers Current provider only Page 29 of 64 September 2014

30 Community Rapid Response Team Out of Hours Nursing (OOH) The OOH Nursing Service works within the wider urgent care system and provides rapid interventions in event of acute episodes of illness. The service is made up of two teams that are co-located with the Community Rapid Response Team. The service will support a mixed caseload of complex and routine patients and is expected to respond flexibly to changing needs. Acute trusts, GPs, GPs Out of Hours service, SWASFT, Community Services, Clevedon Community Hospital, End of Life Care Co-ordination Centre, Care Homes, Care Link (includes self-referrals and carer referrals), Third Sector organisations 9.30 pm am, 365 days a year Nurses, Health care assistants and administration support Current provider only Page 30 of 64 September 2014

31 Community Teams A Community Team is a group of community based multi-disciplinary professionals some of whom have extended clinical assessment, examination and prescribing skills. The team provides both planned and unplanned care services to the patients on the caseload, of which planned care forms the largest part. Support is provided to patients when receiving routine treatment or during an acute phase of an existing long term condition or of a new condition such as a fall. The multi-disciplinary team provides patients on the community ward with individual case management, with a key worker to ensure a co-ordinated care approach is achieved. The focus of the team is to avoid hospital admissions and facilitate early discharge for appropriate patients. Elements of the community teams are linked to the integrated team see s description. All new referrals into the Community Teams should be received via the Single Point of Access (SPA) 08:30 to 22:00 including Bank Holidays and weekends Patients with Medical Status of 3 or 4 will receive treatment 24 hours a day, 7 days a week Generic support workers, nurses, OT, Physio, administration. Health Care Assistants Current provider only Integrated with Adult Social Care on integrated elements Page 31 of 64 September 2014

32 Community Team for People with Learning Disabilities (CTPLD) The Community Team for People with Learning Disabilities (CTPLD) is a joint multidisciplinary team that offers specialist health and social care. The service aims to help people with a learning disability to have the same chances as anyone else to lead a full and interesting life and is committed to addressing health inequalities. This service is centred around service users and their family carers, where the integrated CTPLD ensures ongoing engagement and involvement. In cases where an individual with a Learning Disability or Difficulty does not meet the eligibility criteria, the CTPLD will support them and their family by offering advice and information on other appropriate services that could help them. The service operates an open referral system. Monday to Thursday 08:45 to 17:00 excluding Bank Holidays. Friday 08:45 to 16:30 excluding Bank Holidays Lead Professional, Mental Health Liaison Nurses, Clinical Case Coordinators, Behaviour Specialists, Speech & Language Therapists, Occupational Therapists, Behaviour Nurses, Assistant Practitioners, Support workers, Administrative Assistants Current provider with North Somerset Council and Avon and Wiltshire Mental Health Partnership Page 32 of 64 September 2014

33 Community Team for People with Learning Disabilities Intensive Support Team (IST) The Intensive Support Team is provided as a team integrated into the existing Community Team for People with Learning Disabilities and will support people with complex needs as close to home as possible and place an emphasis on prevention and recovery. All new referrals will follow the CTPLD s referral process am 8.00 pm Monday to Friday. An out-of-hours on-call service (telephone) will be available to out-of-hours services (i.e. mental health; on-call Learning Disabilities psychiatry; emergency duty team). Planned out-of-hours intensive support will be available for service-users eligible for a service from the CTPLD. This may include in certain circumstances nights, weekends and bank holidays Lead Professional, Mental Health Liaison Nurses, Clinical Case Coordinators, Behaviour Specialists, Speech & Language Therapists, Occupational Therapists, Behaviour Nurses, Assistant Practitioners, Support workers, Administrative Assistants Current provider, North Somerset Council and Avon and Wiltshire Mental Health Partnership Page 33 of 64 September 2014

34 Diabetes Specialist Nursing Service (Adult service) The Service provides specialist diabetes nursing for adults with diabetes and specialist diabetes support, education and training to people with diabetes, their families, carers and care professionals. A team of specialist nurses with specialist training and experience in diabetes that see people over the age of 16years that are having complex problems with their diabetes and require specialist nurse review. All health care professionals including primary and secondary care teams can refer Flexible as the service demands but core hours are Monday to Friday excluding Bank Holidays. Diabetes Specialist Nurses Current provider only Page 34 of 64 September 2014

35 Diabetes Specialist Nursing Service (Paediatric) This is a community based service that is commissioned to provide the Best Practice Tariff activity via Weston General Hospital. The BPT is annual payment per patient which covers outpatient (and community) care from the date of discharge from hospital after the initial diagnosis of diabetes is made until the young person is transferred to adult services at the age of 19. All health care professionals including primary and secondary care teams can refer Flexible as the service demands but core hours are Monday to Friday excluding Bank Holidays. Diabetes Specialist Nurses and administration support Current provider and Weston General Hospital Page 35 of 64 September 2014

36 Enablement Support Service The enablement support staff provide an assessment, therapy, support and tracking service for appropriate individuals that access a Nursing or Residential Home in North Somerset. The team member s role will be to facilitate and support service users whilst they are residing in a Care Home making a decision about their long term care. During this time they will provide an appropriate enablement package lasting up to six weeks consisting of continuous assessments, physiotherapy, occupational therapy and nursing support where appropriate. Referrals are made by health and social care professionals Occupational Therapists, Physiotherapists, Nurse, GSWs, Admin Officers 08:30 to 17:00 Monday to Thursday and 08:30 to 16:30 on Fridays. Current provider and North Somerset Council Page 36 of 64 September 2014

37 End of Life Care Coordination Service To provide coordination of an end of life care pathway and framework that supports a comprehensive model of care that enables patients at the end of their life and their significant others, to receive a high quality responsive, multi-professional community service across a 24 hour period. Community Services, Marie Curie, Self-referral, Social Services, Hospice Services, GPs Coordination Centre - 8:30am 17:00 Monday to Friday (excluding bank holidays) GSWs - Monday to Sunday 7 days/ 24 hours Falls Prevention and Management Service Nurses, GSW s and Administration Support Current provider only at present. This is due to change and become integrated with Weston Hospice Care The Service provides specialist multifactorial falls assessment, multidisciplinary management, advice and treatment (including falls clinics) for adult patients with a history or risk of falls within their places of residence including nursing and residential homes within the boundaries of North Somerset GP s, Care Connect, Community Teams, Telephone and Care Homes, Emergency Data and Avon Fire and Rescue 08:30 17:00 Monday-Friday excluding Bank Holidays Nurses, GSW s, administration support. Current provider only but partnership working with Police/Fire Service and Voluntary Sector Page 37 of 64 September 2014

38 Funded Healthcare and Continuing Health Care Team (FNC/CHC) The aim of the service is to assess eligibility for funded care compliant with the National Framework criteria for CHC and FNC. The funded healthcare team provide assessment and review services determining the eligibility for funded care services. The funded healthcare team will act with professional expertise and knowledge, supporting the procurement and monitoring of care packages. The team will also undertake disputes and retrospective reviews. Referrals can be made by a member of the Health and Social Care Community, the patient or any representative acting on behalf of the patient. Monday to Friday 37.5 hours (excluding bank holidays) with service contactable between 9am to 5pm Funded Health Care Manager, Specialist Nurse Assessors, Specialist Nurse Assessor MH, Funded Health Care Administrators, Head of Information Strategy for Funded Care Current provider only Page 38 of 64 September 2014

39 Health Professionals within the Professional Assessment Team (PAT) based in the Single Point of Access (SPA) The purpose of the Single Point of Access (SPA) is to provide improved access for the public and professionals to adult health and social care community services. The establishment of a Single Point of Access including the co-location of a multi-disciplinary health and social care teams enables it to play a key role in providing an integrated community care model. The SPA comprises three parts: 1. Care Connect/Care Link contact centre, 2. End of Life Coordination Centre 3. Professional Assessment Team (PAT). The PAT includes both Health and Social Care Professionals. This element of the service is only for the Health Professionals and the associated support staff provided for the Professional Assessment Team. Health Care Professionals and self-referral via Care Connect/Care Link The PAT will be available from 8:30am to 5pm Monday to Friday, excluding Bank Holidays. Nurses, Occupational therapists, Physiotherapists, Administrative support Current provider and North Somerset Council Page 39 of 64 September 2014

40 Health visitors The health visitor service delivers the Healthy Child Programme to 0-5 year olds. The service offers a family focussed service and has four levels of service Level 1 Communities Offer to empower all families to access services in their communities and where appropriate develop services to meet the needs of young families Level 2 Universal Offer working in partnership with parents and carers to lead and deliver the full healthy child programme from antenatal care through to school entry. Health visiting service is available to all children aged 0 (including antenatal visits) to school entry age. Referrals will be accepted from midwives, parents, children centre staff, GP s as well as other health and social care providers Core hours are 9-5 Monday to Friday (excluding bank holidays) Level 3 Universal Plus Offer identifies vulnerable families, provides, delivers and co-ordinates evidence based packages of additional care, including maternal mental health and wellbeing, parenting issues, families at risk of poor outcomes and children with additional needs Level 4 Universal Partnership Plus Offer works in partnership with parents and agencies in the provision of intensive multiagency targeted packages where there are identified complex health needs or safeguarding needs Named Nurse Safeguarding, Business Manager, Assistant Lead, Safeguarding supervisor, Practice educators, Practice Teachers, Health visitors, Nurses, Safeguarding administrators, Clerical assistants, Administrative assistants Current provider only Page 40 of 64 September 2014

41 Integrated Care Teams A group of community based multi-disciplinary professionals some of whom have extended clinical and social care assessments, examination, prescribing and carers support. The team provides both planned and unplanned care services to patients, of which planned care forms the largest part. Support is provided to patients and service users when receiving routine health or social care interventions or during an acute phase of an existing long term condition or of a new condition. The multi-disciplinary team provides patients with case management, with a key worker to ensure a co-ordinated care approach is achieved for the most vulnerable in the community. The focus of the team is to avoid hospital admissions and facilitate early discharge for appropriate patients and promote independence/self-care. Note Please note that the community teams in the South of the patch are integrated with Social Care. By 2016 all teams will be integrated in the whole of North Somerset. Health care professionals Self-referral 08:30 to 22:00 including Bank Holidays and weekends Each multi-disciplinary integrated team is staffed to reflect the needs of the population with a single management structure and will include a range of staff such as clinical lead, Occupational Therapists, Physiotherapists, Community Nurses, Social Workers, Assistant Practitioners, Generic Support Workers and team administrators. This is the same staffing as detailed in the community team service description. Current provider/north Somerset Council/Avon and Wiltshire Mental Health Partnership Page 41 of 64 September 2014

42 Lymphoedema service (North Somerset, South Gloucestershire and Bristol ) The BNSSG lymphoedema service for Bristol, North Somerset and South Gloucestershire is a nurse led service working collaboratively with other health care professionals both in the primary and secondary care. To provide specialist care, treatment, support and advice to patients with lymphoedema via a specialist team of clinicians and other delegated healthcare professionals as appropriate. To achieve a deliverable, planned programme of training and education for community and practice-based staff across a range of venues/locations that improves the collective range of knowledge and skills necessary in meeting the lymphoedema care needs of the BNSSG population Referrals are accepted from all health care professionals, either from primary or secondary care. The treatment centres operate between 09:00 and 17:00, Monday to Friday, excluding bank holidays. The service is provided by clinical and operational lead and lymphoedema specialist practitioners and is supported by an administrator. Current provider only Page 42 of 64 September 2014

43 Mental Health Placement service To act as clinical case manager for clients with a diagnosis of a functional mental illness who require private hospital, joint funded or long term mental health placements and who currently have an identified care coordinator within the local community mental health team. Referrals can be made by a member of the Health and Social Care Community Core hours of the service are 37.5 hours per week (excluding bank holidays) however there is an expectation that the service must work flexibly to meet the needs of service users and achieve the outcomes of the post. Musculoskeletal Interface and Physiotherapy service Care Co-ordinator Current provider and Clinical Commissioning Group The service provides care for patients with musculoskeletal injuries and disorders that have diagnostic uncertainty and provision of care for patients that have pain and dysfunction arising from the musculoskeletal system that are able to attend an outpatients department. Health Care Professionals The service is available 5 days a week, with clinics at various times to meet patient demand Multi-disciplinary team with administrative support. Current provider only Page 43 of 64 September 2014

44 No Worries and No Worries + No Worries is a confidential health service for young people under the age of 25. The service offers a range of information and advice including relationship advice, provision of contraceptives and STI testing and treatment, in addition support and referral for mental health, stop smoking, alcohol and drug misuse. The service is also responsible for providing sexual health training to the wider workforce and facilitating a bi annual network to support trained No Worries staff members. Self-referral, parent/carer, health or social care provider or school staff To be determined by the provider but must be accessible to target audience Specialist Nurse, Outreach nurse, Support worker, Admin Current provider only Parkinson s Disease Specialist Nurse 2 year pilot ends July 2016 A Specialist Parkinson Nurse post has been created within the community neuro team to work alongside established Specialist Nurses in MS and Stroke. The post will be funded for a total of 2 years by Parkinson UK. The specialist nurse will provide specialist support in the community to the complex Parkinson s patients and their carers in addition provide training and education to other health care professionals. Health Care professionals days a week Specialist Parkinson Nurse, Admin support Current provider and Parkinson s UK Page 44 of 64 September 2014

45 Residential home support service The overall aim of the service is to facilitate provision of, and access to, high quality health care in residential home settings to improve the quality of care that residents receive and reduce the number of unplanned/emergency admissions to hospital. This will be achieved by supporting care homes to implement and maintain best practice for managing a number of basic health conditions commonly experienced by an older population, using global trigger scores, and improving the pathway for accessing existing community and primary care services. Nursing Homes in North Somerset that are part of the current service Monday Friday. Nurses, Dementia Liaison worker, administration support. Current provider and Avon and Wiltshire Mental Health Partnership Respite service (Orchard View Only) This service is provided to those people within the Orchard View service at the time of closure. It is a closed group and others may not be added. The cost of this Respite Service, including the Respite Coordinator resource, will be met by the three Clinical Commissioning Groups (CCGs) of North Somerset, Bristol, and South Gloucestershire No new referrals to this service. As required by the service users. Respite Coordinator Current provider only. Page 45 of 64 September 2014

46 School Aged Immunisation Service To commission and deliver a comprehensive and high quality immunisation service for school aged children. Specifically in 2014/15 this includes: Deliver an HPV vaccine to reduce morbidity and mortality from cervical cancer by routinely offering the vaccination to 12- to 13-year-old girls. Deliver the Men C and Td/IPV booster vaccine to protect the population against meningococcal disease resulting from bacterial infection and tetanus, diphtheria and polio by routinely offering the vaccination to 13- to 14-year-old girls and boys. The service will be population-wide and evidence-based with the aspiration of 100% of individuals being offered immunisation in accordance with the Green Book and other official Department of Health and Public Health England guidance. The schedule of immunisations offered to school aged children is subject to review by the Joint Committee on Vaccination and Immunisation (JCVI) and therefore may change in future. In particular, seasonal flu vaccination is expected to be offered to primary and secondary school aged children within the next 3-5 years. This service must be able to respond to changes in national and local requirements. All children of suitable age School hours + evening drop-in/catch up clinics Nurses Current provider only Page 46 of 64 September 2014

47 School Nursing Service The school nursing service delivers the Healthy Child Programme to all school aged children (5-19). The service delivers an evidence based service that provides public health interventions and health care support to young people and their families to enable them to make the most of education and wider social opportunities, to improve health and health outcomes for young people and families. In addition the service provides all school based immunisations. School nursing service is available to all children attending state funded schools, academies, pupil referral units, special schools or are home educated in North Somerset Referrals will be accepted from children and young people, parents, teaching staff as well as other health and social care providers Core hours are 9-5 Monday to Friday (excluding bank holidays) Named Nurse Safeguarding, Business Manager, Assistant Lead, Safeguarding supervisor, Practice educators, Practice Teachers, Health visitors, Nurses, Support workers, Administrators, Clerical assistants Current provider only Page 47 of 64 September 2014

48 Specialist Older People Team New Service under development The new Specialist Older Peoples Team comprises a Consultant Geriatrician and Nurse Consultant and a Community Pharmacist (with appropriate admin support). The Team will provide increased senior clinical decision making to the health system complimenting pathways that are already in place. This new team will not replace current pathways moreover it has been developed with two key principles 1. To re-enforce the GP role as holder of care 2. To compliment current care pathways The proposed model consists of both acute and community facing SOPT clinicians, working together to increase the capacity of senior geriatrician decision making in North Somerset. The team will undertake early assessment appraisal, monitoring care and treatment of patients in a community setting, adding support to general practice through expert advice and guidance, facilitating the planning and implementation of comprehensive care packages, supporting timely admission and discharge from hospital and offering leadership to the work of the residential care home team. This is expected to result in an increase in avoided admissions and facilitated early discharge also resulting in reduced lengths of stay with a secondary care environment. Health care professional Monday Friday, 9am 5pm excluding bank holidays Consultant Geriatrician, Nurse Consultant for Older People, Clinical Pharmacist and Administrative support Integrated Current provider and Weston Area Health Trust Page 48 of 64 September 2014