workshop 1 presentation

Community Hospital Review – The Clinical Model
What did we recommend?
Dr. David Carson, Director,
The Primary Care Foundation
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
© Primary Care Foundation
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
© Primary Care Foundation
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
© Primary Care Foundation
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
• Takes account of local availability of staff
© Primary Care Foundation
Overall description of
clinical model
• Consultant leadership and review twice weekly across all
• 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)
© Primary Care Foundation
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
• 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
• Twice weekly presence on the ward – maintained despite oncall commitments at acute hospital
© Primary Care Foundation
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
• Long term commitment from staff and trust
© Primary Care Foundation
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
© Primary Care Foundation
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
© Primary Care Foundation
• 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
© Primary Care Foundation

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