(PPT) Community Hospital Review – The Clinical Model What did we recommend? Dr. David Carson, Director, The Primary Care Foundation - DOKUMEN.TIPS (2024)

Community Hospital Review – The Clinical Model

What did we recommend?

Dr. David Carson, Director,The Primary Care Foundation

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Opportunities in new integrated trust

• Draw on larger pool of expert community nurses

• Increase links to general practice and community staff

• Blur the boundary between the community and hospital care

• Potential economies of scale across the five hospitals

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Good clinical practice• Patients should not have delays waiting for decisions

• Evidence shows rapid senior decisions result in better outcomes: suggest daily ward rounds with medical and rehabilitation goals reviewed every morning (advanced nurse practitioner (ANP), and/or GP, and nurse and discharge coordinator present ) decision making at start of day

• Aim for consistent and regular expert clinical input

•Once per week is not adequate - ensure consultant ward rounds are twice a week and senior clinician – either Consultant or GP with a specialist interest (GPsi) leading the multidisciplinary team (MDT)

• Expertise needs to be maintained at weekends and out of hours – potential to increase therapy input at weekends to facilitate discharge

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Principles … 1

• Establish a common set of competencies across all units

• These should be sufficiently flexible to encompass local variation in admissions and case mix (GP direct admissions)

• Affordable

• Builds on existing strengths

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Principles … 2

• Builds on staffing resource in wider trust

• Allows a process of continual decision making and review

• Delivers baseline competency and expertise 24- hours every day

• Takes account of local availability of staff

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Overall description of clinical model • Consultant leadership and review twice weekly across all

wards

• GP expert input to all wards daily

• Advanced Nurse Practitioner (ANP) cover all wards 9 - 5 Monday to Friday

• Weekends, evenings and overnight ANP on call for all wards supported by medical on-call rota (Trust assumes full responsibility for cover out of hours)

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Consultant role

•Overall responsibility

•At helm of early senior decision making – responsible for setting clear management plans and rehabilitation goals with the multi-disciplinary team (MDT) – they must be present at MDT

•Clinical leadership and mentoring – provide source of expert advice to all personnel especially ANP and GP

•Responsible jointly for length of stay and other key quality indicators with ward manager / part of clinical governance framework

•Twice weekly presence on the ward – maintained despite on-call commitments at acute hospital

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GP role

• Expertise in care of older people

• Career development, training and mentoring

• Responsible for daily decision making and progress of rehabilitation assessment

• Build on existing expertise and roles across community hospitals

• Long term commitment from staff and trust

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ANP role … 1• Daily presence to support care of patients starting with Board

Round with other staff ( eg therapist / discharge co-ordinator ) at start of day

• Assessment and Prescribing ( we expect ANP to have core competencies – e.g. clinical assessment of patient; basic diagnosis-making, e.g. chest /urine infections; management of common scenarios, e.g. fever , hypoxia , hypotension, hypoglycaemia, confusion, GI bleed etc. )

• Assessment on daily basis with decision making on daily basis

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ANP role … 2

• Progress actions, assessment, investigations and therapies so that goals are reached in expected time and problems identified early

• Ensure individual patients care plans are progressed. Ensure ANP is able to ask for senior advice at any time, so decisions are not delayed

• Ensure robust clinical governance system is in place

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Implementation

• Commissioners used findings from our study to develop a specification in cooperative discussions with the trust

• Trust and commissioners now have the same goals

• Everyone underestimated the focus needed for implementation