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.”

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74,000 registrants with ECCH

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The Integrated Care System

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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

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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

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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

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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

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Integration with Mental Health Teams: DIST

Out of Hospital Team North

Waveney Out of Hospital Team

What’s next?

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