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Scarborough and Ryedale Community Services
PTL February 2020
Frailty, Elderly Medicine and Community MDTs
Scarborough and Ryedale Community Services….
Scarborough Core PCN Filey and Scarborough Healthier Communities PCN
Ryedale PCN
S&R Service Provision….
• Rapid Response: Multi-Disciplinary Community Team support (8am—8pm)• District nurses: nurses and healthcare assistants (8am—10pm)• Community therapies: physiotherapists, occupational therapists, generic support workers (8am-
10pm)• Holistic, multi-agency community frailty pathway, incl; Pharmacy support / Elderly Medicine • Respiratory CNS Team and Pulmonary Rehab Service (patient classes) • Home Oxygen Delivery Service• Cardiac CNSs and Cardiac Rehabilitation Service (patient classes)• Heart Failure CNSs• Diabetes CNSs and Diabetes Education Service• Continence Service and Continence Product Service• Tissue Viability CNSs• Dietetic Service• Speech and Language Therapy• Muscular Skeletal Out Patient Service (MSK)• Community Stroke Service• Inpatient Ward – Fitzwilliam Ward, Malton Hospital• Continuing Health Care (CHC) includes Fast Track / Funded Nursing Care • Customer Access Service (CAS)
S&R Community Frailty Model
Principles:
• Holistic, multidisciplinary, multi-agency service
• Personalised, joined-up and coordinated around individuals
• Comprehensive assessment – including Edmonton Frailty Score
• Single point of access into service via CAS
• Practise / hub team frailty register
• Inextricably linked with Community Elderly Medicine Service
What does the team provide?
Our service takes referrals from GPs, other community services, acute hospitals
Aim to improve the lives of people identified as frail or who have either been admitted to hospital 3 times or more in the past year or recently discharged from hospital
Patient visits in own home, holistic assessment commenced by the most appropriate clinician from the team including: memory screening; medications review; discussions re- wishes and preferences future care
Information sharing with GP / other relevant professionals including YAS Ambulance Service (with consent)
Follow up visits to ensure plans are meeting desired outcomes
Frailty Assessment….
S&R Partnership Board objective – to review various frailty assessment tools
Community – Trusted Holistic Assessment + Edmonton Frailty Score:
Edmonton Frailty Scale: a multidimensional frailty measure that can be used for case-finding, to estimate severity, and to enhance care planning
http://www.nscphealth.co.uk/edmontonscale-pdf
S&R Community Frailty Model…
Common problems in frailty which team can help with include:
Falls
Cognitive impairment
Continence
Mobility / physical inactivity
Weight loss and poor nutrition
Polypharmacy
Low mood
Alcohol excess
Smoking
Vision problems
Social isolation and loneliness
Frailty Service leaflet…..
Community MDT Elderly Medicine Clinics
Commenced: October 2019
All S&R community patients who require Elderly Medicine MDT review need to be referred to HTFT CAS (previously RSS)
Exclusion Criteria service:
• Medically unstable or at high risk of significant deterioration requiring admission to hospital
• Conditions where alternative specific pathway; movement disorders/neurological conditions
• Complex functional illness requiring specialist care (includes functional illness where significant risk of harm, exhibition of extremes of challenging behaviours or sexual dis-inhibition)
• Access to complex, frequent or specialist diagnostic imaging services
• Where no diagnosis can be offered and is requiring continued specialist services
Community Intervention:
• Triage and Holistic assessment
• Community based care (MDT + Consultant resource)
• +/- Refer on to alternative / additional services
Community MDT Elderly Medicine Clinics
Clinic venues:Malton Hospital Coming soon……Scarborough - Eastfield clinical hub
Currently run monthly
The Team: Core - Clinical Lead, Community Nurses and Therapists: Physiotherapy, Occupational therapy,
clinical pharmacist, Medical Consultant, Community support practitioners
Specialist Practitioners: Dietitians, Speech and language, Heart failure, Respiratory, Diabetes, Cardiac, Tissue viability, Bladder and bowel…..
Collaborative working with GP, NYCC Social Services, Acute Trust partners
Access to voluntary care sector services – drawing upon the wide ranging support within our community assets and social prescribing organisations
Medicines Optimisation Team Humber Community Services
The Community Services MDT is pleased to welcome2 medicines optimisation pharmacists - Sarah Tyrer and Anna Adjei-Doku1 medicines optimisation technician - Sarah Lee
The team is based at the Scarborough and Ryedale Hubs: Tennyson Avenue, Eastfield Surgery and Malton Hospital
Supporting the community services teams to provide a clinical medication review service with a focus on frail patients in the community: Clinical medication reviews for patients that are housebound or having difficulty attending
surgery Reviews for patients at Fitzwilliam ward enabling smooth discharges and reviews for patients at
risk of falls Medication reviews in our elderly medicines clinics
Referrals: via CAS - SystmOne / [email protected]
Contact details:SystmOne (Task) – User group: Pharmacy (Humber FT Scarborough & Ryedale Community Services)Sarah Tyrer: mobile – 07971361783; email: [email protected] Adjei-Doku: mobile – 07971552526; email: [email protected] Lee: mobile – 07971552378; email: [email protected]
Services to support Community Patients….
Services within
Scarborough.docx
List of local contacts….embedded doc:
Quality Outcomes:
Healthy active ageing
Supporting independence
Living well with simple or stable long-term conditions
Living well with complex comorbidities, dementia and frailty
Rapid support close to home in crisis
Good acute hospital care when (and only when) needed
Good discharge planning and post-discharge support
Good rehabilitation and re-ablement after acute illness or injury
High-quality nursing and residential care for those who truly need it
Choice, control and support towards the end of life
Coming soon……..MDT – Frail Patient support
S&R Partnership Board objective…
Develop integrated and coordinated MDT's with all partners
MDT will have the ability to respond rapidly to a crisis or unexpected care need (physical, psychological or social) that left unattended will result in rapid deterioration or hospital admission
Create a single point of access to a MDT and ensure effective administrative support
Ensure that services developed through ED frailty service & MDT's are aligned
Working group commenced scoping exercise / learning from other MDT examples
Local awareness events – Falls and Frailty in the Community…
S&R Partnership Board objective / Local CQUIN outcome
Local partner organisations involved in falls and frailty services to be invited to hold a stall to promote what their organisation provides around falls safety and prevention, including help for those people who do fall, and to build upon how each of these organisations link to and can support each other
Plan for provider-only events, not open to the general public
Dates:March / April – dates to follow
Venues:Whitby - HospitalScarborough - Rugby ClubRyedale - Norton Bowling Club
Additional and Integral community service developments…
• Expansion of core community service provision – 7 day provision, 8am-10pm
• Diversionary Pathway – Falls / Rapid Response with YAS - June 2019 ongoing
• Community Care Home Beds –Pilot July 2019, Expanded for Winter pressures –working with Acute Trust, CCG, NYCC, Primary Care
• Daily Safety Huddles – Scarborough / Malton -working with NHS Improvement Team / open access for clinical discussions and escalation for patients at risk –MDT discussion and care planning
• New clinical roles – Band 4 Core and Specialist posts, Nursing Associate roles
Diversionary Pathway – Falls / Rapid Response…
Community Daily Safety Huddles
3 key messages…
1. Refer via CAS for frail community patient holistic assessment….there is an MDT team to support frail patient assessment and care planning, including access to a community Elderly Medicine clinic and community pharmacy resource
2. Be aware of the many services – including charitable and voluntary sector organisations – that can support community patients to live well
3. Listen out for ongoing developments to support frail patients…..MDT, awareness events, falls training, diversionary pathways…..
S&R Community Leadership Team Contacts:
Name Job Title Telephone email
Sarah Locker Service Manager (Scarborough) 07976939046 [email protected]
Roxanne Woolcott Team Leader (Scarborough) 07811837075 [email protected]
Lynne Symonds Team Leader (Scarborough) 07890600098 [email protected]
Emma Babbage Team Leader (Scarborough) 07966184041 [email protected]
Klaire Lightowler Clinical Coordinator (Scarborough) 07976408316 [email protected]
Liz Harrison Clinical Lead (Scarborough) 07580609790 [email protected]
Rachel Laud Clinical Lead (Scarborough) 07966175874 [email protected]
Rishi Sookraj Service Manager (Ryedale) 07801455656 [email protected]
Jo Marshall Team Leader (Ryedale) 07966183756 [email protected]
Alison Gibson Clinical Lead (Ryedale) 07747442319 [email protected]
Customer Access Service (CAS) N/A 01653609609 [email protected]
Sonia RaffertyService Manager (Whitby & Malton Wards)
07971599398 [email protected]
Carol Wilson Locality Matron Community Services 07801260066 [email protected]
Jeanette Hyam Locality Matron Community Services 07973693024 [email protected]
