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Integration – empowering
people to stay at home NHS Great Yarmouth and Waveney
Integrated Care System Noreen Cushen-Brewster & Heather Howman
“Nothing between us that we cannot resolve.”
18/03/2015 1
74,000 registrants with ECCH
18/03/2015 2
The Integrated Care System
18/03/2015 3
ADMISSIONS AVOIDANCE • Reduce unplanned care admissions
• Keeping people out of hospital
DISCHARGE • Early assessment
• Timely
• Care in right place
• Avoid readmission
UNPLANNED
CARE • Early diagnosis
• Right care, right place
• Reduced length of stay
One
team
One ICS One
commitment
One
shared
vision
Seven Day
Services
PERSON
Initial Key
Focus Areas
18/03/2015 4
Patients told us it’s what they want – to stay at home
It offers -
• Better patient experience; retain independence
• Recover faster & more fully
• Improved dignity
• Reduced exposure to communal
acquired infections
It helps the GY&W system -
• Reduced number of emergency
admissions
• Reduced length of stay /
timely discharge
• Reduced reliance on long term
care placements
Patient, Family, Carer
GP
Independent Nurse
Prescribers
Senior Community Nurses & Therapists
Social Work Practitioners &
Assessors
Rehabilitation & Re-
ablement Practitioners
Generic Workers
Community Phlebotomists
Day Coordinators
(Health) & Duty Workers
(Social)
Administrators
Why a 24/7 Out of Hospital Model?
Beds
with
CARE
Single Point of Access
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The Integrated Community Care Hub
Kirkley Mill Campus, Lowestoft
• Out of Hospital Team
• GPs, in and out of hours
• Therapists and Podiatrists
• Community Nurses and Phlebotomists
• Social Work Practitioners
• Community Mental Health Practitioners
• Pharmacists
• Community Support Workers
18/03/2015 6
Lowestoft Out of Hospital Team; April to
January 2014/15
“Making my life much easier than it would have been without their help”
Out of Hospital Team
Beds with Care
Referral Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Total
Total 51 56 69 64 70 71 116 116 121 108 310
Referral Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Total
Total 6 3 1 6 7 6 8 8 8 11 64
18/03/2015 7
Lowestoft Out of Hospital Team; April to January
2014/15
“Able to provide better and quicker care”
05
101520253035404550 Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
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Case Study
Before
Patient known to have dementia
Frequent dizzy spells
Recurrent falls over 5 day period
Wider family struggling to cope
Joint assessment within 1 hour of referral, including full bloods
After
Appropriate equipment in the home
Spouse able to assist with exercises
Carers in place
Wider family reassured of safety
Mental Health Services informed
18/03/2015 9
Integration with Mental Health Teams: DIST
Out of Hospital Team North
Waveney Out of Hospital Team
What’s next?
18/03/2015 10