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 No. of Admissions to H@H June 18 - Jan 20 50 • June 2018 – part team, Mon-Fri, 45 ESD 1 st patient ToC 40 • Dec 2018 – introduced 35 Number of Admissions 30 admission avoidance in one 25 Locality via GP or ANP for 20 Visiting Service (PCIP); GP 15 Responsible Clinician 10 • Jan 2020 – all GP Practices refer 5 for Admission avoidance; both 0 referral routes but shift to AA 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

ACHSCP - Sustainability Plan Who Service level How % of Hospital population Hospital level Ward MT working Seamless patient pathway consultant & Hospital Treatment acute & board rounds MDT Appropriate step up/down of GP, community Virtual ward integrated care provision Intense community geriatrician, Acute Care @ Home round (daily) acute community MDT review by MDT 20% Virtual ward Community Intense community Enhanced community support round (weekly) MDT therapy review by MDT Community Review assessed care needs Stable therapy 20% by Care mgmt. (informed / Stable treatment / care in the community MDT & Care and care reviewed by community mgmt MDT) Personal + Independent living Self-management Self support network

Thank You