Virtual Ward Pilot Staffa Health

1. Hardwick Clinical Commissioning Group Virtual Ward PilotStaffa Health

2. Hardwick Clinical Commissioning Group Introduction • Outlier for emergency admissions • Care of frail elderly and patients with complex needs reactive and uncoordinated • Figures 07-08: • SAR all ages 107 • SAR 65+ 116.3 • Readmissions within 28 days: all ages 10%; 65+ 13.4%

3. Hardwick Clinical Commissioning Group Introduction cont. • Visited Croydon to look at their Virtual Ward model • Aware of Unique care model introduced at Shires • Wanted to build on the good work CM already doing • Work in a more integrated way with DN team and Acute care

4. Hardwick Clinical Commissioning Group Staffa Health VW Model • Embedded in Primary Care • Adopted principles of Unique Care: case management; integrated working with SS and joint assessments • CM lead professional • Close working ICS, SN, Palliative care

5. Hardwick Clinical Commissioning Group Staffa Health VW Model cont’d • Care co-ordinator as Ward administrator • Integrated working with DN team • GP Champion • VW Process Flow Chart • Patient Leaflet • Practice Leaflet

6. Patient Case History Hardwick Clinical Commissioning Group • Mr B. 79yr old man with COPD, Bladder Cancer, Pernicious Anaemia, Pneumoconiosis • Home visit because of swollen ankles, increasing SOB, declining mobility. • LTOT but sats only 78% on air increasing to 85% on 4L O2. ImpnCorPulmonale. F/U with Home Oxygen Team chased. Commenced on Furosemide and increased ventolin dose. Referred for ECHO and to VW as assessed to have complex needs and to be at risk of admission • S/B CM and SW on joint visit – paper work and appt arranged by CC

7. Patient Case History Cont’d Hardwick Clinical Commissioning Group • Clinical care under review by CM. Support from SS declined at the moment but SW now familiar with situation so when deteriorates can organise support quickly. • When seen by Steve Collis for O2 assessment unwell and sats not recovering. Organised admission. In hospital over night and advised that there was nothing else that they could do for him. • CM has had several visits to the house over the last 2-3w. Has discussed preferred place of care/DNAR etc. Rightcare completed. Will review ECHO when available and liaise with GPs re future management. DNs aware of the situation as will be involved in EoL care.

8. Hardwick Clinical Commissioning Group

9. Hardwick Clinical Commissioning Group Main outcomes • Joint working with SS – mutual learning experience. Access to each others records invaluable. • In reach into Acute Care – Matron to Matron discussion. Supported by joint matron forum. • Rightcare • Improved EOL/Advanced care planning

10. Hardwick Clinical Commissioning Group Main outcomes cont’d • Joint working with DN team • Care co-ordinator – co-ordinates ‘intelligence’ and maintains board with list patients in hospital • Evaluation demonstrated excellent patient and staff satisfaction. • ‘Bucked’ the trend for emergency admissions for Derbyshire

11. Patient quotes: Hardwick Clinical Commissioning Group “Everyday tasks have been much easier” “Nice to be able to talk about Dad’s medical problems” “Peace of mind for the family” “I have a more positive attitude” “I know that help is near if required” “The service provided is first class” “It’s easier by not having to get to the doctors or go into hospital”

12. Staff quotes Hardwick Clinical Commissioning Group • It has had the following influence on my work:- • Better understanding of complex care management • Improved ease of accessing appropriate medical and social support for patients with complex needs • Tracking patients is useful • Improved continuity of care

13. Hardwick Clinical Commissioning Group

14. Hardwick Clinical Commissioning Group

15. Hardwick Clinical Commissioning Group

16. Hardwick Clinical Commissioning Group

17. Hardwick Clinical Commissioning Group Way Forward • Consider rolling out the model across all practices – model modified to specific area • Build on current in reach work to achieve full Integrated care – e.g. Matron Forum • Facilitate early discharge from Acute Care • Expand specialist support in the community e.g. Community Geriatrician, Support Worker for Dementia