Aberdeen City H&SCP Denise Johnson, Team Leader Vicky Locke, - - PowerPoint PPT Presentation

Hospital at Home – Aberdeen City H&SCP

Denise Johnson, Team Leader Vicky Locke, OT/Trainee ACP

The Journey So Far…..

• Dec 2018 - TL and a Business Case
• Recruitment Process – Jan 2018 to Feb 2019
• Team – ANP; PT; OT; NP; SHCSW; Pharm Tech; Admin
• Adapted model – Responsible Clinician is GP; 2 days/week

Community Geriatrician; Twice weekly MDT with Care Manager and Consultant Geriatrician; direct access to GAU & on-call Geriatrician

• Joined up services – H@H; Community Geriatrician; City Visits (PCIP

urgent care)

Referral Pathways – Admission Avoidance & Active Recovery

• June 2018 – part team, Mon-Fri,

ESD 1st patient ToC

• Dec 2018 – introduced

admission avoidance in one Locality via GP or ANP for Visiting Service (PCIP); GP Responsible Clinician

• Jan 2020 – all GP Practices refer

for Admission avoidance; both referral routes but shift to AA

5 10 15 20 25 30 35 40 45 50

Number of Admissions

• No. of Admissions to H@H June 18 - Jan 20

Active Recovery Admission Avoidance

What’s worked well

• Patients/Families/Unpaid Carers –happy with service (evaluation

report first 6 months)

• Developing the service – team involvement
• Well educated workforce - MSc Advanced Clinical Practice; PG Cert

Urgent Care; Enablement Care;

• Blending professional roles
• Connections with established teams – e.g. OOH; SW
• Informing and supporting local strategy – QI projects/ stepped care

approach

Our Challenges

• Local and National Recruitment issues – difficulty recruiting to

Consultant Geriatrician post / required to redesign model

• Staff Education v Service Delivery – maintaining 7-Day Service and

supporting development of K&S

• Small team, city wide
• Embedding H@H is our ongoing positive challenge – ongoing QI

projects

Hospital Treatment Acute Care @ Home Enhanced community support Stable treatment / care in the community Independent living

Service level How Who

Hospital level acute Hospital consultant & MDT Intense community acute Intense community therapy Stable therapy and care Ward MT working & board rounds Virtual ward round (daily) review by MDT

GP, community geriatrician, community MDT Community MDT Community MDT & Care mgmt Personal + support network Virtual ward round (weekly) review by MDT

Review assessed care needs by Care mgmt. (informed / reviewed by community MDT)

Self-management Self

20% 20% % of population

Appropriate step up/down of integrated care provision

Seamless patient pathway

ACHSCP - Sustainability Plan

Thank You