We ’ re passionate about

2. We’re passionate about • Putting patients first • Quality, safety and patient experience • Transforming services to meet the health needs of future generations

3. Community Integrated Assessment TeamCIAT North Tees and Hartlepool NHS Foundation Trust Out of hospital services Emma Campbell – Senior Clinical Matron Bob Warnock – Clinical Care Co-ordinator

4. What is CIAT? GP Support Admission Patient Illness Rehabilitation Occupational Therapy Hospital Care at Home Intermediate Care Community Falls Therapy support Accident and Emergency Rapid Response Nurse Physiotherapist Healthcare Referral Social Services Care Package Rehabilitation ?

5. Who is in CIAT? • Rapid response nursing • Community therapy teams • Emergency care therapy teams • Discharge liaison team • Residential rehabilitation units

6. Aims of CIAT • To provide people with short-term support in the community. • To provide timely intervention that will facilitate safe discharge. • To facilitate the co-ordination of unplanned care. • To enable patients to stay in the community during an episode of illness • To provide care for up to 6 weeks depending on the needs of the patient. • To optimise both nursing and therapy intervention throughout the Patient’s journey.

7. Patient Journey - CIAT

8. Patient Background • 85 year old male • Normally independently mobile with walking stick outdoors short distances – in decline • No formal care package • Lives with 84 year old wife in a private house • Functionally independent • Medical history: Multiple joint arthritis, Heart attack 2010, Cataracts, Reduced hearing

9. History of the Injury • Patient reported 2 day history of a productive cough • Patient woke in the night to access the toilet • Felt light headed lost balance in the dark • Landed heavily on Right Knee • Managed to get off floor and go back to bed • Woke next morning in pain and struggled to move knee or weight bear on knee • Attended by GP who started patient on antibiotics and sent patient to A&E • A&E – X-ray / diagnosis soft tissue injury to Right knee • Patient ref to Emergency Care Therapy Team (ECTT)

10. CIAT - ECTT Purpose: to prevent avoidable admissions into hospital beds • ECTT attend patient following medical intervention • Complete a generic therapy assessment • Identify patients normal function • Identify patients current functional and physical limitations • Identify patients risks to a safe discharge home

11. ECTT Plan • Patient unable to stand without assistance due to pain • Concerns on how patient will manage at home with wife supporting • Team feel that patient currently needs 24 hour care support currently to support with functional needs • Team contact residential rehabilitation unit and organise admission into a rehabilitation bed

12. Residential Rehab Purpose: To provide 24hour care and rehabilitation in a non medical residential setting • Clinician completes further assessment of patient • Physical assessment • Functional assessment • Social assessment • Abbreviated Mental Test • Bone Health Screening

13. Residential Rehab Plan • Exercise programme for knee • Range of movement exercises • Strengthening and flexibility exercises • Gait re-education using a walking frame • Care plan designed to support assisted dressing/washing

14. Patient Progression • Over the next 2 weeks patient begins to progress with mobility • Pain reduces with knee • Therapist attends patient property to assess for supportive equipment and adaptations • Day 11: Support Staff report patient becoming a little muddled and they suspect that patient has developed a urinary tract infection • Residential Rehab Unit contact Rapid Response Nursing Team • Nurse attends unit to test urine • Nurse commences patient immediately with antibiotics • Over the next days patient improves and progresses to discharge

15. Residential Rehab Plan • Equipment provided to support discharge; • walking aid • Bedside commode • Raised toilet seat and frame • Raised arm chair • Shower board • Identify ongoing short term care needs • Rehab Unit discharges patient home with Intermediate Care Services

16. Intermediate Care • Purpose: To provide short term care and rehabilitation within a patients own home • Care provided to support washing and dressing a.m and p.m • Rehab recommenced through CIAT rehab assistants • Patient continues to progress, care reduced, knee function improves, patient function improves back to independence • Referral Out • Disability Living Officer

17. GP A&E Emergency Care Therapy Team Independence Intermediate Care Team Residential Rehab Rapid Response Nursing

18. Next steps……… • Clinical triage • Health and social care SPA • Continue to build on the success of CIAT • Further review and development of care pathways.

19. Thank you Any questions?