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ESD

ESD. Catherine Williams Vicky Johns Peterborough Community Services. Today we aim to …. Explain why we have chosen to develop ESD Describe the current community stroke provision in Peterborough Look at the process

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ESD

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  1. ESD Catherine Williams Vicky Johns Peterborough Community Services

  2. Today we aim to … • Explain why we have chosen to develop ESD • Describe the current community stroke provision in Peterborough • Look at the process • Describe the challenges and positive experiences we have encountered along the way • Look at where we are now

  3. Why aim for ESD? • All the evidence points to ESD being the model of best practice for people coming out of acute care back into their homes (RCP, NSS, NICE) • More importantly, because we want to improve community stroke services for the population we serve

  4. The current position • No specific stroke services commissioned in Peterborough beyond the acute phase • Only the Intermediate Care Service able to offer a multi-disciplinary service to people including those with a stroke • ICS not regarded in literature as being stroke specific • No additional funding available for service developments

  5. Current position • Silo-ed uni-professional services eg physiotherapy, OT, SALT etc • Multiple hand-offs between services • Duplication of assessment • Poor carry-over • Zero continuity of care • Limited stroke specific-skilled practitioners • Professional and service conflict • Dispersal of provider organisation

  6. The process to date • Allocated funding to 31st March 2011 for Community Stroke Coordinator • Monies allocated from Dept Health (Adult Social Care) budget for 14 months of above post • Built excellent links with local Network – Anglia Stroke and Heart Network

  7. The process … • ASHN co-hosted two workshops with PCS staff • Asked staff to map current services and identify gaps • Examples of current good practice • Engendered a sense of joint responsibility and opportunity to make things better • Provided a safe space for people to be open and honest • Staff identified the need for a Community Stroke Team

  8. The process …. • By the 2nd workshop we were aware of the Accelerated Improvement Programme • Reached agreement that ESD would form part of the service offered by the community stroke team • Meeting with commissioner to explain current situation and our proposal for CST and ESD. Agreement gained from commissioning to continue to develop our thinking pending the completion of a service specification

  9. Challenges … • Lack of clarity around current commissioned pathways • Managing expectations • Managing organisational barriers between community and acute providers

  10. … and positives • Senior management recognition of problems and need for change • Lots of enthusiasm and drive from PCS staff to change and improve the service for people who have had a stroke • Improved relationships with colleagues in acute trust • Commissioners now focused on commissioning services according to the accelerated metrics

  11. Where are we now? • Agreed a pragmatic approach to trial the ESD pathway • Identified key people – physio and OT • Secured agreement with in-house home care to support ESD trial with re-ablement staff • Agreed draft criteria for acceptance onto ESD trial • Will support 3 patients through the ESD pathway during August • Use outcomes from trial to inform the implementation of the ESD pathway in November (when new hospital is due to open)

  12. Proposed ESD criteria • Patient medically stable • Patient able to transfer with assistance of 1 (therapy staff and main carer) • Home visit has been carried out to promote safe environment • Patient has good carer support • Continence and nutritional risks are managed • Patient/carer able to deal with an emergency • There are no tissue viability issues

  13. Desired outcomes from trial • Enable patients to benefit from home-based rehab rather than stay in hospital after medically stable • Ascertain level of input required • Identify any gaps • Build staff confidence through experiencing process • Provide a high quality service when ESD “goes live” in November

  14. Where are we now? • Commissioning now in process • Management team sign off of proposed pathway • Working with HR to pull appropriate staff into Community Stroke Team • Liaison with acute trust regarding CST in-reaching to identify people for ESD

  15. Contacts Thank you for listening Catherine Williams & Vicky Johns Any queries, please contact Vicky Johns or Cathy Semple Community Stroke Coordinators vicky.johns@nhs.net / csemple@nhs.net

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