Health & Social Care Coordinator Procedures · consenting patients will be contacted by telephone to discuss various aspects of ECP. The survey results will be anonymised. We would

Health & Social Care Coordinator

Procedures

Battersea Healthcare CIC are here to help should you require any assistance:

Telephone: 020 3198 9706

Email: [email protected]

Website: www.bhcic.co.uk/pact

H&SCC role objectives

ECP Champion

Be the font of knowledge whilst we roll out ECP and beyond.

Patient

Be there for the patient and their carer when they need you.

GP Practice

Helping the GP to get the best for the patient.

Local Services

To help patients make effective use of services.

MDTs

To make the MDT as effective as possible for your patients.

The ECP pathway The Enhanced Care Pathway enables proactive system to be in place to help reduce the likelihood patients being admitted to hospital. The care plan provides valuable insight for clinical staff and helps all patients receive the most appropriate care, An overview of the pathway is shown below:

Using EMIS effectively

At the practice

Maintaining an up to date EMIS record is critical as it will ensure a good flow of up to date information is shared with other services. Practices are well versed in the use of EMIS and some of the following tips may help:

You are encouraged to keep your patients on the PACT Full Service register rather than the AUA Register otherwise you do not get to see all of the plan;

Make sure your pop up alerts are on (managing alerts settings). Always put the date on the alert;

Make sure you read code the patient being on ECP using read code 8CMW.

EMIS Community

There is limited access to EMIS at the Community Adult Health Services (CAHS) teams, however, using EMIS Community this is being extended to a wider range of the clinical team. The screen shots below shows what this looks like:

Specific instructions will be issued when it is rolled out but as they are using EMIS Community, CAHS notes will be viewed using the shared view functionality.

Care plan What is a care plan for?

When a GP produces a care plan it effectively sets out the agreed goals between the patient and the GP. It also describes what should happen in the event of a crisis or unplanned episode of care. There are some parts of the care plan that CAHS (Community Adult Health Services) need to ensure that they are able to accept the care plan and schedule the next steps. These are:

Updating Care Plans

When saving Care Plans use a different date, e.g. the date you are making the changes.

H&SCC to undertake regular checks to make sure updates are being actioned

Consent There are three types of consent which are:

Sharing information with the MDT;

Sharing information with the CSU;

For the patient to be contacted as part of a patient feedback exercise. The PACT consultation template asks for consent or dissent as required and you should follow your local procedures for obtaining consent if it has not been recorded. 1. Consent from the patient for their information to be shared with the MDT. (Read code: 9NdG or 9NdH)

As the patient is going to be discussed in a clinical forum or Multi-Disciplinary Meeting, consent is asked at the PACT consultation. The MDT is there for the benefit of the patient to ensure that they are receiving care from the most appropriate teams and the experience of the MDT can help ensure that a specialist reviews their particular circumstances to ensure the best care plan is in place. The care plan must include the consent and CAHS will not accept the care plan without it. If a patient dissents from sharing their information with the MDT, they cannot be registered as an ECP patient and should be managed in PACT as usual. 2. Consent to share information with Commissioning Support Unit (read code: 9M4 or 9M5)

As this is a pilot, the commissioners are measuring how effective it is by tracking several factors. Hospital services are an expensive resource and we are hoping that by proactively care planning the unscheduled admissions are reduced which will reduce the costs to the commissioner. Those savings are needed to help pay for the enhanced care pathway which means the patient receives the best care possible and the commissioner is able to manage resources much better. We would encourage all patients to consent to this as it is limited information provided and will help ensure ECP is sustainable. 3. Patient experience (read code 9y)

Patient experience is vital to ensure that ECP is positively improving their care and meeting their needs. The only person who can give this insight is the patient themselves. A selection of consenting patients will be contacted by telephone to discuss various aspects of ECP. The survey results will be anonymised. We would encourage patients to consent to this short 20 minute telephone call and where they do, please record this on the patient's record.

Special Patient Notes Special Patients Notes are also known as “SPNs”. As London Ambulance Service (LAS) may be called to a patient's home, they can be made aware that the patient is a part of the ECP500 through the "special patient notes" which are available to several healthcare providers such as LAS, out of hours, 111, and so on. The usual form should be completed usually by the patient’s GP (an example is shown below) which should be sent to SELDOC when it has been completed.

In the LONG TERM CONDITION section, you should complete the following text: “This patient is on the Enhanced Care Pathway. This means that they are in the top 500 people in Wandsworth who are at highest risk of sudden deterioration and emergency hospital admission. The patient has a care coordinator (tel: XXXXXXXXXXX, Mon-Fri Xam-Xpm) and a key worker (tel: XXXXXXXXXXX, Mon-Fri Xam-Xpm) who can be contacted to discuss this patient. The patient’s care plan is embedded below. It is accurate as of XX/XX/XXXX.” The patient’s care plan should be attached to the email when sending it to SELDOC.

Contacting patients and carers Initial contact

When speaking with a patient for the first time, trust and rapport will be at different levels depending upon how well, if at all, you know them. To help develop a rapport, you can:

Be prepared, calm and give due time;

Create a safe environment where trust can flourish;

Remember names and key facts;

Demonstrate empathy;

Suspend judgment;

Be congruent So calling your patient for the first time from reception may not be the best way to develop rapport. Trust will follow once the rapport develops and the patient knows that you will deliver on your promises and have their best interests at heart. This first contact may be in one call or you may wish to deliver the key messages over a few calls. These early opportunities are to introduce yourself and pass or gather information with the patient including;

Their GP feels that they would benefit from being reviewed by a team of specialists;

Give your direct dial number (or by pass number if you do not have one). This is for them or someone who cares for them and should not share it with anyone else;

Regular contact to see how things are going and if feeling unwell, please call me directly;

Do they have any friends or family they would like to give permission for you to speak with?

Make sure you have the correct details for the patient and carers, (and enter the necessary changes on EMIS);

If they have any problems or delays with services to let you know to see if you can help;

You will do as much as you can but sometimes there are processes which must be followed;

Maintaining contact

Keeping regular contact is a vital component of the role as it helps identify as early as possible if a patient is deteriorating in their health. This information can be passed to the patient’s GP who can assess if anything needs to be done to help the patient. Over time, the frequency of contact will naturally develop. If you are familiar with your patient we recommend contact with your patient once a week for the first three weeks and then it depends on the patient, agree with your patient thereafter how much contact you will have. Do not forget to update EMIS where required.

Basic

Influencing

Describe

Empathise

Express

Solution

Consequence

Managing disagreements

Sometimes your influencing skills may not work and you will need to come to a common agreement or be better placed to resolve something which has gone wrong. This may be the patient, a carer, or possibly a service provider. Here is a 9 step approach to help you come to an agreement: Templates

Patient leaflet The patient should be given the ECP500 leaflet as it outlines what ECP is details what information is shared and why this is. We would suggest downloading the leaflet as and when it is required as it is likely to be frequently updated. http://bhcic.co.uk/wp-content/uploads/2016/05/Sharing-personal-information.pdf

http://bhcic.co.uk/wp-content/uploads/2016/05/Sharing-personal-information.pdf

Clinical Meetings

Multi-Disciplinary Team Meetings (MDTs)

MDT’s are held for specialists to discuss a patient and decide what will best meet their needs both now and possibly in the future. Specialists who attend the meeting can vary and typically consist of: GP’s, Matron’s, District Nurses, Specialist Nurses, Social Worker, Social Care Officer, Community Geriatrician, Maximising Independence Team, Community Mental Health, and Age UK. When and where are they?

MDTs are hosted by the Community Adult Health Service (CAHS) and are held weekly at the four locality hubs:

Locality Day Time Clinic

North Wednesday 14:00 Stormont Clinic

East Tuesday 14:00 Southfields Group Practice

South Thursday 14:00 Tooting Health Clinic

West Wednesday 14:00 Westmoor Clinic

Once you have submitted your Care Plans CAHS will contact you and offer dates for the GP and you to attend the MDT. It is encouraged that you attend the first few in person with the GP to build a relationship with the team. You can either attend in person or by teleconference; CAHS will provide the telephone number and access code to dial in which are shown below:

Locality Area Telephone Number Pin Code

North Battersea, Clapham

0844 473 73 73

847105

East Southfields,

Wandsworth, Earlsfield

131063

South Tooting, Balham and Furzedown

559186

West Putney,

Roehampton 477697

Practice MDTs

Some practices hold MDTs which may also involve ECP patients. You may wish to speak with the MDT organiser to see if you would benefit from attending these. They are typically held monthly.

Local Services

• Mental Health & Dementia Services • Dementia Assessment & Support for behaviours that

challenge (all ages)

• Community Neurological Rehabilitation • Drug and Alcohol Services

• Wheelchair Service • Community Learning Disability • Diabetic Specialist Nursing • Integrated Falls & Bones Health Service • Complex Case Management • Rapid Access Clinic • Dietetics Services • Podiatry Services • Continence Services • Phlebotomy • Respiratory Specialist Nursing • Therapies (Maximising Independence) • Heart Failure Specialist Nursing

• Geriatrician on Demand • Dental Services • Sexual Health

• Older People’s Advice & Liaison Service (OPALS)

• Trinity Hospice • Tissue Viability • Acute Admissions Avoidance (AAA)

• Age UK • District Nurses • End of Life Care (EOLC)

• Community Adult Health Services (CAHS) • Social Services • Befriending Service

AGE UK

Overview

Visiting patients at home to assess their needs. Supporting patients to access grants for household items such as white goods and furniture. Providing support to access welfare benefits and checks, providing help with financial assessments for home care, arranging private care packages. Assisting patients to move into suitable accommodation including helping to complete housing applications, writing letters to support the patient’s application to move, contacting housing departments by telephone and email. Liaison with patient’s relatives if consent is given and inform them of the input and referrals.

Contact details Tel: 020 8812 5678 Fax: 020 8812 5001

Carers Partnership Wandsworth

Overview Provides a range of services to support adult carers in the borough, including; information & advice; peer support; back care & therapies; training and respite.

Contact details Tel: 020 8877 1200 Email: [email protected]

Community Learning Disability

Overview Specialist input to adults with learning disabilities. The team offer a range of assessment and intervention.

Team •Community Nurses •Dieticians •Occupational Therapists

•Physiotherapists •Psychologists •Speech and Language Therapist

Open Monday – Friday 09.00 – 17.00

Contact details Tel: 020 8812 7000 Fax: 020 8812 7005

Community Neurological Rehabilitation Overview Neurological rehabilitation for people with a neurological condition.

Team •Physiotherapists •Occupational Therapists •Speech and Language Therapists •Neuropsychologist


Contact details Tel: 020 8812 5000 E-mail: [email protected]

Community Nursing

Overview Provide advice and treatments for conditions such as leg ulcers, pressure sores, ear syringing and taking blood.

Team Nurses

Open 24 hours per day, 365 days per year


Complex Case Management

Overview Care and support for people with complex needs/multiple conditions where a coordinated approach to their care is required.

Team • Community GPs •Pharmacists •Advanced Nurse Practitioners


mailto:[email protected]

Continence Services

Overview Specialist continence assessment for the appropriate continence products. The nurses will also provide training and support for practice staff.

Team Specialist Nurses



Dementia assessment and support for behaviours that challenge (all ages)

Overview Memory Assessment Service (MAS) and Behaviour and Communication Support Service (BACSS)

Team Psychologists, Dementia Support Nurses

Open Monday - Friday 09.00 – 17.00

Contact details Tel: 020 3513 6320 Out of Hours Crisis Line - Tel: 0800 028 8000

Dental Service

Overview Dental care in the community for adults with complex needs who have difficulty getting treatment in their high street dental practice e.g. the elderly.

Team •Dentists •Dental Nurses •Dental Assistants


Contact details Tel: 020 8544 2346

Diabetic Specialist Nursing

Overview Education, support and care for complex and poorly controlled diabetic patients.



Contact details Tel: 020 8812 5000

Dietetics Service

Overview Specialist assessment and nutritional advice for people with a clinical condition.

Team Dieticians


Contact details Tel: 020 8812 4155 Fax: 020 8812 4059 E-mail: [email protected]

Heart Failure Specialist Nursing

Overview Care and support for patients with diagnosed heart failure to review their medications, help with fluid balance monitoring.


Open Monday – Friday 09.00 – 17.00 Nurse on-call service for telephone advice on Saturday, Sunday and Bank Holidays - 10.00 – 16.00.

Contact details Tel: 020 8812 5000 E-mail: [email protected] Tel: 020 8812 5000

Home from Hospital

Overview

Check that they have enough food and drink available and that their home is warm Light shopping and housework, helping to organize paperwork e.g. bills. Helping someone to do gentle exercises e.g. walking short distances Dropping in for a chat, accompanying someone to collect their pension or to a social activity, collecting prescriptions or encouraging them to use the delivery service. Helping to book transport for hospital follow- appointments.

Contact details Tel: 020 8877 8942 [email protected]

Integrated Falls & Bone Health Service

Overview Multi-factorial falls and fracture risk assessment in the home and interventions including exercise and activity advice.

Team •Physiotherapists •Exercise Facilitators •Rehabilitation Assistant

Open Monday – Friday 08.00am – 18.00


Mental Health & Dementia Services

Overview Assessment and diagnosis of mental health conditions (e.g. anxiety, depression, schizophrenia, bipolar disorder, personality disorder)

Open Monday – Friday 09.00- 17.00

Contact details

Under 75 years: Wandsworth Single Point of Access Tel: 020 3513 4421 Over 75 years: Older People’s Community Mental Health Team (CMHT). Tel: 0203 513 6320.

Older People Advisory Liaison

Overview Two nurses and daily Geriatrician cover aim to provide comprehensive geriatric assessment for frail patients.

Team Geriatrician, 2 Nurses


Contact details Tel: 020 8672 1255 (STGH Switchboard - Geriatrician carries Bleep 7173, Nurse has Bleep 7172

Phlebotomy for non-CAHS housebound patients

Overview This service is available for housebound non-CAHS patients for phlebotomy and blood pressures delivered by Health Care Support Workers.

Team Health Care Support Workers

Open Monday – Friday 09:00 – 17.00

Contact details Tel. 020 8812 5000 Email: [email protected]

Podiatry Service Overview Podiatry service for housebound patients

Team Podiatrist




Contact details

Referral must be made by a GP or a healthcare professional Tel: 020 8487 6426 Fax: 020 8487 6424 E-mail: [email protected]

Respiratory Specialist Nursing

Overview Assessment, care and support for patients with diagnosed or suspected chronic respiratory disease.



Contact details

Tel: 020 8812 5000 E-mail: [email protected] Nurse on-call service for telephone advice on Saturday and Sunday Tel: 0776 031 2219

Tissue Viability Nursing

Overview Specialist tissue assessment, advice and treatment for leg ulcers, pressure sores, complex wounds and chronic oedema.




Trinity Hospice Overview The Wandsworth Care Coordination Centre provides pain and

symptom management, emotional support, end of life care and bereavement support, a central point of contact to arrange services for patients who have end of life care needs so they can be cared for in their own home. Arrange equipment (except wheelchairs), act as a helpline to give you information, advice and support, and organise overnight nursing care to give families an opportunity to rest.

Team Doctors, Palliative Nurses, Physiotherapists, HCA


Contact details Tel: 0300 300 0116 Fax: 020 7787 2005 Email: [email protected]

Community Mental Health

Overview

Community Mental Health Teams offer assessment and diagnosis of Mental Health conditions (e.g. anxiety, depression, schizophrenia, bipolar disorder, and personality disorder) Promote mental health and improve awareness of its importance Support people mental health problems and their families, Provide care and treatment to the highest standards.

Team Psychiatrist, Consultants

Open Monday – Friday 08.00am – 18.00

Contact details Tel. 0203 513 5000 or 020 3513 6320

Community Neuro Team

Overview The Primary Care Therapy Team provides assessment, advice and treatment for people without a neurological impairment, who are unable to access out-patient services or where Therapy in their



home or community setting best suits their needs.

Rehabilitation service to patients who have suffered injury or have had their physical ability reduced by illness.

Team Physiotherapists, Occupational Therapists, Speech and Language Therapists, Rehabilitation Assistants


Contact details Tel: 020 8812 4060 Fax: 020 8812 4059 Email: [email protected]

Therapies (Maximising Independence)

Overview Rehabilitation service to patients who have suffered injury or have had their physical ability reduced by illness.

Team Physiotherapists •Occupational Therapists •Speech and Language Therapists



Social Services

Overview

We help adults with care and support needs and those who care for them. This could be because of frailty, a disability, a long term health condition, a short or long term illness, caring responsibilities, or your health and wellbeing is at risk for any other reason.

We offer information and advice to everyone. If you want more help from us we will ask you about your care and support needs, or your support needs if you’re a carer, to assess if you qualify. If you do not qualify for our support, we will help you contact other organisations and services which may be able to help.

Team Social Worker, Social Care Officers,

Open Monday – Friday 09:00 – 17.00

Contact details Tel: 020 8870 7707 [email protected]

Wheelchair Service

Overview Assessment for pressure cushions, wheelchairs and seating for people with a permanent disability affecting their ability to walk.

Team Therapists


Contact details Tel: 020 8487 6084. Referral must be made by a GP or a therapist. Form on St George’s website.

Wandsworth Housing Adaptations & Repairs Forum

Overview

To provide support for vulnerable Wandsworth residents to enable them to live safely, securely, warm and independently in their own homes. To carry out housing adaptations and repairs as well as providing other services e.g.: Befriending service, issues concerning heating failure and boiler checks, adequate access to properties.

Contact details Tel: 020 3198 8945 Email: [email protected]



Support

Contacting the Support Team

The PACT Support Team are here to help should you require any assistance:

Telephone: 020 3198 9706

Email: [email protected]

Website: www.bhcic.co.uk/pact

HSCC webpage

We have developed a web page for all H&SCCs to easily access relevant and up to date information. Look and book mark the page today: www.bhcic.co.uk/hscc If you have any ideas, information, resources, websites, and so on that you feel your fellow H&SCCs would find useful, please let us know. Virtual Forum

We have developed a virtual forum for H&SCC’s for discussions and sharing ideas. If you are a H&SCC, please contact us for us to send you an invitation.

The group can be accessed via our HSCC website: www.bhcic.co.uk/hscc.

http://www.bhcic.co.uk/hscc

http://www.bhcic.co.uk/hscc

Checklist: ECP patient

Date

Patient name

EMIS no

GP

H&SCC

Action Notes / Dates

Care Plan checks

Care plan has been completed by GP.

☐

- MDT consent confirmed ☐

- CSU consent checked/noted ☐

8CMW read code on EMIS ☐

Questionnaire consent ☐

Special Patient Note sent ☐

Care plan (advice or referral) indicated

☐

Care plan emailed to CAHS ☐

CAHS confirmed receipt ☐

Contacting the patient

Phone call to patient ☐

Scheduled follow up calls ☐

Patient leaflet ☐

Letter sent to patient ☐

Phone call to patient’s carer ☐

Scheduled follow up calls to carer

Carer leaflet

Letter sent to carer

V1

Keeping in Touch

Date: Patient’s Name:

Date: Name of Patient’s Carer (if applicable):

Notes:

Actions Due Completed

☐

☐

☐

☐

☐

Advise GP? ☐ Update EMIS? ☐

V1

Checklist: MDT

Patient name

EMIS no

MDT Date MDT Time MDT Venue / Dial in

Action Notes / Dates

Confirming MDT attendance

Confirmed if attending / dialling in

Attendee: GP

Attendee: H&SCC

Confirmed with attendees

Confirmed with CAHS

Preparation

Check care plan is up to date

Copies of care plan printed to take to MDT

Any questions to be answered

Advise patient of MDT

Outcomes of MDT

Advise GP? ☐ Update EMIS? ☐

Documents

Health & Social Care Coordinator Procedures · consenting patients will be contacted by telephone to discuss various aspects of ECP. The survey results will be anonymised. We would