baseline model of care for proposed community wards appendix 1
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North SomersetNorth Somerset
Baseline Model of care for proposed community wards
Appendix 1
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Pyramid of care & care functions
Components of Community wards
Common referral processes
Discharge
North SomersetNorth SomersetCare status and service response
Hospital
Community Wards, including use of Independent Sector Nursing
Homes
Primary & Community services
Self care with Local Health & Wellbeing resources
Care statusCare function
North SomersetNorth SomersetComponents of the Community Ward
North SomersetNorth Somerset
R,R&R
Community Matrons
MH
Rehab
LTC
EoL
ELDERLy
Self Care
Ward Team Admin
Acute communityWard (HDU)
Ward management/Neighbourhood team
GP
SocialCare
Proposed Community Ward Model
Acute Hosp.
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RR&R named nurse linking directly with neighbourhood team named nurse, managing the most acutely unwell, then transferring into ward
Ward admin leading on the admission and discharge process, linking with named nurses, GPs and community matrons
Community matrons leading on the clinical support for the team, managing their caseload and the capacity of the service
Community Ward Team Responsibilities
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GPClinical leadership for the ward/team, providing medical cover and support. Referring directly into team.
SocialCare
Directly linked/named social care support, working closely with named nurses and community matrons
Neighbourhood team to include therapies, and leads within specialist areas- End of Life, Mental health, long Term Conditions, Care of the Elderly and Rehab.
Community Ward Team Responsibilities
North SomersetNorth SomersetCommunity Ward Core Teams
Clear discharge
plan agreed at admission
7 days a week service with an
out of hours service of 10 pm – 7am
North SomersetNorth SomersetCommon referral process
North SomersetNorth SomersetDischarge
North SomersetNorth SomersetCommunity Ward Out of Hours service
North SomersetNorth SomersetLocality Teams & other local links
North SomersetNorth SomersetSpecialist Community Services
Services across 4 Localities and 7 Community Wards
North SomersetNorth SomersetAccess to Hospital Services & Hospital out reach
North SomersetNorth Somerset Shared protocols.
Referral process.
Case Management.
Access to Equipment.
Long Term Care Database.
Transport into and out of A&E departments- reducing reliance on Ambulance Services.
Closer links with GP in A&E- RR&R nurses based alongside, timely Communication to prevent admission.
Community Ward Enablers
North SomersetNorth Somerset Close links with Out of Hours services and Ambulance services to prevent
admissions.
7 day working for all professions.
Capacity management methodology to move resources to where it isrequired, based on the demand, to include out of hours communityprovision.
Telehealth to support those with chronic condition and prevent deterioration.
RiO in community service to improve communication between services –links required to GP, acute and Social Care systems.
Access to timely diagnostic results, allowing community clinicians to makeswift decisions for the management of the person.
Community Ward Enablers
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