Abstract
In alignment with 1 ( Shared values and vision), 3 (people as partners in care), 4 (resilient communities new alliances), 5 (workforce capacity and capability) and 9 ( transparency of progress, results and impact) of the nine pillars of integrated care The South Cotswold Primary Care Network impact hub is a Single point of access for professionals and services working with people with frailty and was designed to facilitate and improve communication between GP practices and professional teams, support the flow and navigation between services, build relationships with and between professionals, understand and access the available and most appropriate pathway to maximise system efficiency, follow up with individual patients on discharge that have been identified as at risk and needing further input with services and ultimately to be South Cotswolds Hub that can be used to explore what services are available locally and how to access them.
To make this happen the FAS and HAT developed a process to simplify communications about a patient between these teams and the south Cotswold physio therapists through a phone call or email to the Hub.
This process facilitates the appropriate sharing of information, care plans, ReSPECT and other key information. This process also accommodates the update of the GP records, acceptance of referral and informing of the frailty clinician of the situation or discharge of the individual.
The second part of the process was developed with the Community hospital and the SCFS to improve communications between the teams regarding individuals known to the team and on the case load, offer referral and invitation to IMPACT MDT meeting if appropriate, support with discharge as needed and arranging post discharge follow up’s.
Next step. Case Study – Due to the relationships built between the teams. A case study was undertaken on a patient that was a frequent attender to ED/FAS, the patient is a diabetic with uncontrolled BS, She has also a memory issue which contributed to her admissions. She was then brought to MDT (linking HUB & IMPACT MDT) where DN’s and FAS were able to discuss this patient and express their concerns to ASC. From this MDT – Patient had care calls and now has had a reduction with hospital admissions.