Integration – empowering people to stay at home

NHS Great Yarmouth and Waveney Integrated Care System

“Nothing between us that we cannot resolve.”

The Integrated Care System

ADMISSIONS AVOIDANCE•Reduce unplanned care admissions•Keeping people out of hospital

DISCHARGE•Early assessment•Timely•Care in right place•Avoid readmission

UNPLANNED CARE

•Early diagnosis•Right care, right place•Reduced length of stay

One team

One ICSOne

commitment

One shared vision

Seven Day Services

PERSON

Initial Key Focus Areas

Patients told us it’s what they want – to stay at homeIt offers -•Better patient experience; retain independence•Recover faster & more fully•Improved dignity•Reduced exposure to communal

acquired infections

It helps the GY&W system - •Reduced number of emergency

admissions•Reduced length of stay /

timely discharge •Reduced reliance on long term

care placements

Why a 24/7 Out of Hospital Model?

Beds

withCARE

Single Point of Access

The Integrated Community Care Hub

Kirkley Mill Campus, Lowestoft

•Out of Hospital Team

•GPs, in and out of hours

•Therapists and Podiatrists

•Community Nurses and Phlebotomists

•Social Work Practitioners

•Community Mental Health Practitioners

•Pharmacists

•Community Support Workers

Lowestoft Out of Hospital Team; April to August 2014

Referral Apr-14 May-14 Jun-14 Jul-14 Aug-14 Total

Total 51 56 69 64 70 310

Referral Apr-14 May-14 Jun-14 Jul-14 Aug-14 Total

Total 5 5 1 5 3 19

“Making my life much easier than it would have been without their help”

Out of Hospital Team

Beds with Care

Lowestoft Out of Hospital Team; April to August 2014

“Able to provide better and quicker care”

Lowestoft Out of Hospital Team

Emergency acute admissions Age 35 plusLowestoft   Lowestoft   Variance Variance2013 - April to July   2014 - April to July      

1868   1700   -168 -8.99%

       

-151

-8.08%Remainder of GY&W   Remainder of GY&W   2013 - April to July   2014 - April to July  

3006   2978   -28 -0.93%

SUS Data – (April to July)

“It helped me walk quicker”

Changes in occupied bed days (April – July)

Emergency Admissions

2013 - April to July

2014 - April to July

14413 13751 -662 -4.59%

Case Study