BGS Scotland - Autumn 2017

Transcription

1 The Highland approach: Working together in Community Hospitals. Bridge-building across the Ness Dr Claire Lunt, Consultant MFE, Raigmore Hospital Dr Nikhil Agrawal, GP & Clinical lead RNI, Southside Medical Practice

2 BIG geographical area 233,000 population Highland Health & Social Care Service Excl. Argyll & Bute Community Health Partnership Workforce in MFE 5.2 FTE Consultants 1.6 FTE Assoc Specialist ~100 GP practices Collaborative links essential but challenging

3 Differences in categorising community hospitals nationally Significant variability currently Different models of care 13 Community Hospitals within Highland Health & Social Care

4 How have we changed our practice in the Community Hospital Care in Inverness? Which model? Wordle

5 S BG Sc o nd tla -A ut um n 20 17

6 Community Hospital in Inverness: Royal Northern Infirmary (RNI) 30 bedded unit 2 wards Mix of admissions Rehabilitation post-acute hospital admission Orthopaedic / Stroke / Post-surgical / Medical Palliative patient with complex needs Community step-up Delayed discharges

7 RNI: Change in model 1999 to Current GP practices inputting Patients t/f from DGH & community to care of GP Predominantly nurse led Reactive GP input Communication challenges Reduced nursing time due no. of visiting clinicians No joint medical / nursing / therapy decision making in discharge planning

8 Timeline Health & social care integration Development of community hospital workforce Appetite for joint working and shared care between primary & secondary care colleagues

9 Linking primary & secondary care: Aims Enhance access to Comprehensive Geriatric Assessment Embed consistent support network for GP led service Build confidence to treat patients with more complex conditions Reduce acute hospital readmissions / increase discharges Enhance consistency, support & education

10 Factors that enabled consideration of new model for secondary care... Funding for additional Community Geriatrician post Vision to align GP practices with named Consultants Similar successful model at other site (Invergordon)

11 How did it happen? Transition from multiple practices to just Southside practice 2013 SLA offered from board Applications invited Formal interview process Plan proposed as to how to run the services Regular review of patient twice a week in ward round Medical presence in MDT and discharge planning Dedicated time to patients and families for communication

12 Model of care 2 GPs providing regular input Approx hours/week Medical cover 8.30am 5.30pm Monday-Friday Admitting & Clerking patients from DGH & community Treating intercurrent illness Complex discharge planning Communication/MDT with team & families

13 Model of care Once weekly MDT ward round Consultant /GP / Pharmacist / Nurse/ Students Weekly joint MDT started Nursing / Medical / AHP / Home care organisers & SW Public holiday cover Weekends covered by GP OOH service

14 Nurses view Reduced amount of time spent to phone surgeries More time for clinical care Felt supported Continuity of care Standard approach by doctors Improvement in Learning Delirium, cognitive impairment sepsis, SEA etc Reduction in falls with MDT work

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16 What primary care colleagues think Improved communication between primary / secondary care Reduce admissions to DGH Reduced referral to OP clinics OOH GP/ UCP get clear info from typed notes, resus status, TEP etc Unwell and complicated patients, challenging for already pressurised OOH GPs can admit directly to secured beds Access to subacute care and specialist investigation CGA

17 Our view at Southside Practice Complexity in our rota Team extension and flexibilty Increase diversity Learning improvement Single point of contact with sec care Community reviews, ACPA, Polypharmacy Remuneration

18 Structure that has now developed Medication review Weekly MDTM Weekly MDT WR SER DNACPR / POA discussions Ceiling of treatment decisions

19 STAFF Team structure development Enhanced Morale Reduced staff turnover Confidence of staff Empowerment of nursing staff PATIENT Consistent & proactive approach CGA approach to all admissions Anticipatory care planning Reduced patient interhospital transfer Increased confidence with complex patients Benefits that we have seen COLLABORATION Documentation Ceiling of treatment documentation Communication Mutually beneficial learning process between GP & Physician

20 Challenges faced? Initial high intensity input to embed approach Delayed discharge transfers Communication Communication in acute sector promising definitive POC IDLs not being completed from acute hospital Communication when on days off / LTFT OOH OOH assessment / clerk-ins

21 Current Limitations Significant proportion of Delayed discharges Care at Home Significantly limited resource Care home placement LOS increased / OBD at a maximum Significant time waited in acute sector for transfer to CH for rehab

22 Conclusions Motivated & engaged GP team Enhanced partnership leads to virtuous circle of learning between GP & Physician Functionality of unit as a whole has improved Enhanced Patient-centred care with access to holistic CGA approach for every patient Reduction in acute hospital readmissions, unclear impact on emergency hospital admissions currently Working together well - primary & secondary care in RNI