NHS Basildon & Brentwood Clinical Commissioning Group. Unplanned & Planned Care Pathways. Adam Cronin BBCCG - Version 2 (April 2013),

Transcription

1 NHS Basildon & Brentwood Clinical Commissioning Group Unplanned & Planned Care Pathways Adam Cronin BBCCG - Version 2 (April 2013),

2 Contents Unplanned Care Community Hospital Step up beds 2 Single Point Of Referral (SPOR) 3 Primary care & assessment treatment centre (PCATC) 4 Integrated Community Geriatrician 5 Diabetic Foot (Basildon) 6 Diabetic Foot (Brentwood) 7 Planned Care Rapid Advice Service for Haematology 8 MSK / Tier 2 9 Community Ophthalmology 10 Community Dermatology 11 Contents

3 2. Community Hospital Step up Beds Inclusion Criteria Inclusion criteria - acute illness not requiring admission to acute hospital not expected to exceed 7 day length of stay Step-up rehabilitation from community - not acutely unwell (not requiring rapid diagnosis or intensive hospital type support) Mild COPD - unable to cope at home, mild to moderate breathlessness, general condition deterioration Community acquired pneumonia - clinical judgment supported by CRB65 severity score should be applied; if 1 or 2, consider referral Mild dehydration - should patient require IV fluids Falls not requiring diagnostics, x-ray, etc. Function deterioration of condition to include medication titration Unstable diabetes - not requiring sliding scale insulin intervention Palliative Care - symptom control and management Frail Patients Exclusion Criteria Respite Care Mental instability, acutely confused e.g. Delirium Acutely unwell - requiring intensive medical care Acute or unstable psychiatric disorder requiring specialist psychiatric input Detoxification need from drugs or alcohol Urgent social care services need unless the primary need is for health care Service user must be 18 years or over and have been assessed by GP. Assessment and treatment can include; IV Antibiotic therapy, IV Fluids, Pain management, Bloods transfusion, Cellulitis management, Referral to appropriate care programme, Functional deterioration of chronic neurological conditions, Medication review and Dementia - if known dementia/cognitive decline but no other mental health problems and no evidence of delirium Accessing step up beds Brentwood Locality (Mon Fri 9am 9pm) Contact the Primary Care & Assessment Treatment Centre (PCATC) Telephone: Billericay, Basildon & Wickford Locality (Mon Fri 9am 5pm) Contact Mayflower Hospital Telephone: Community Hospital Step up Beds

4 3. Single Point of Referral (SPOR) What is Single Point of Referral? (SPOR) Single Point of Referral (SPOR) is available for patients that are at risk of a hospital admission with an aim of providing rapid health and social intervention, to maintain patients in their normal residence (home/ care home). Inclusions 18+ for patients that are at risk of a hospital admission. The service provides rapid assessment (within 2 hours of referral) with access to integrated intermediate health & social care services. The service accepts referrals from all health & social care professionals How do you access the SPOR Service? For all practices of Basildon & Brentwood CCG Contact Number: Between the hours of 9am 5pm Monday Friday excluding public bank holidays GP, Other professional or Home Care Provider Acute Hospital Single Point of Access (SPA) SPOR receive a call from one of the above where depending on the nature of the patient the team will implement one of the following: (a) Health professional visit to the patient (b) Social care visit to the patient (c) Joint Health & Social Care visit to the patient (d) re-direct the call to the appropriate service listed below Depending on the outcome of the assessment, the team may access the following services. Social Care Health Teams Tele Care Interim and Respite Beds Poplar reablement flats BCH & Mayflower Community Hospital Integrated Community Team Primary Care & Assessment Treatment Centre (PCATC) Stroke Hub Team Essex Care Reablement Dementia Intermediate Support Team Day Hospital (Brentwood) Community Geriatrician Clinics 3. Single Point of Referral (SPOR)

5 4. Primary Care & Assessment Treatment Centre (PCATC) Inclusion Criteria patients aged over 18 patients must have been seen by their GP on the day of referral The Primary Care Assessment and Treatment Centre (PCATC) provides services for adults who, following an initial assessment within primary care, require further multi-agency assessment, monitoring or treatment, but without recourse to secondary care and avoid an A&E/ secondary care assessment. diagnosis of presenting complaint detection and management of predisposing and associated conditions, e.g. UTI, chest infection appropriate treatment and/or referral to specialist services referral to Integrated Community team for support during health crisis and/or rehabilitation programme environmental assessment and installation of equipment and aids where necessary referral to secondary care if appropriate full information to patient s GP of all diagnostics/treatment provided and outcome liaison with Essex county care social team Exclusion Criteria onset of new neurological signs suggestive of stroke onset of new cardiac symptoms acute abdomen trauma with head injury, wounds or suspected fracture any loss of consciousness aged under 18 years any existing mental health condition, the GP will need to discuss with the nurse in charge of the appropriateness in terms of safety and compliance to treatment. patient with suspected or confirmed infective diarrhoea patients who require complex palliative care or symptom management. Accessing the Primary Care & Assessment Treatment Centre (PCATC) For Basildon, Brentwood, Billericay & Wickford Localities Contact Number: (between the hours of 9am 9pm) A shared care on SystmOne will be required if the referrer is a SystmOne user 4. Primary Care & Assessment Treatment Centre (PCATC)

6 5. Integrated Community Geriatrician Model Referral Criteria Patients 75 years or over deemed to be at high risk of unnecessary acute admission and meet one or more of the following criteria: 3 or more acute admissions within past 12 months; Cognitive decline/isolation/living alone; 2 or more Long Term Conditions Identified as having quality care or safety issues Multiple medications Rapid Access / Planned First Community Outpatient Clinics Residential Care Home Multi- Disciplinary Team Reviews Locality Based Multi- Disciplinary Team Reviews Patients referred by their General Practitioner will receive an individual assessment, treatment and management plan for their condition. The medically-led service model will be delivered from each of the three Community Day Hospital settings in south west Essex inc: Billericay, Brentwood and Thurrock. The Service will provide mental, physiological and functional assessment of patients within key Residential Care Homes identified by the Clinical Commissioning Groups. General Practices associated to each Care Home will be contacted by the lead Consultant Geriatrician to discuss and agree their approach ahead of each review. The Service will provide mental, physiological and functional assessment of patients within key Residential Care Homes identified by the Clinical Commissioning Groups. General Practices associated to each Care Home will be contacted by the lead Consultant Geriatrician to discuss and agree their approach ahead of each review. Accessing Integrated Community Geriatrician Model For Basildon, Brentwood, Billericay & Wickford Localities Referrals can be made via Telephone: (01277) or Fax: (01277) Referrals can be made via Choose & Book or Referral Management Services Locality based MDT Reviews can be requested via the Community Geriatric Service administrator (Sue Douglass ) 5. Integrated Community Geriatrician Model

7 6. Diabetic Foot Pathway - Basildon Low Current risk STAGE 1 foot The At Risk Foot STAGE 2 (a) Foot The High Risk Foot STAGE 2 (b) Foot STAGE 3 FOOT Ulceration STAGE 4 FOOT Ulceration and infection STAGE 5 FOOT: The Devitalised Foot Diabetes present but no other risks: Normal Sensation Normal Pulses No deformity Presence of 1 risk factor: Neuropathy or Absent pulses or Foot deformity Neuropathy & absent pulses +/ deformity or previous ulceration episode, now healed. Relative Risk of ulceration is 80 times the risk for those in green box Superficial Ulceration and skin fissures, no evidence of infection. Or? Charcot s warm swollen foot but no ulcer and no architectural distortion present The Infected Foot Stage 4 Where the patient is systemically well and no necrotic or devitalised tissue is visible. Or with new Charcot s when architectural distortion already present The Infected Foot Stage 5 Patient is systemically unwell Devitalised tissue present Necrosis Visible/protruding bone Gangrene Managed by GP Practice Patient education leaflet Annual review Managed by GP & Podiatry Patient education leaflet Review interval determined by podiatrist Managed by Podiatry & Orthotics intensively: Ring Fax Urgent Podiatry Referral If Charcot s suspected, patient to minimise weight bearing on affected foot: Ring Fax Same Day Urgent Podiatric referral OR Diabetic Foot Clinic Ring OR Dr Mulcahy/Horndon Ward or X 1952 Refer to Hospital MDT Foot Team Dr Mulcahy Ring OR Horndon Ward ext Diabetic Foot Pathway - Basildon

8 7. Diabetic Foot Pathway - Brentwood Low Current risk STAGE 1 foot The At Risk Foot STAGE 2 (a) Foot The High Risk Foot STAGE 2 (b) Foot STAGE 3 FOOT Ulceration STAGE 4 FOOT Ulceration and infection STAGE 5 FOOT: The Devitalised Foot Diabetes present but no other risks: Normal Sensation Normal Pulses No deformity Presence of 1 risk factor: Neuropathy or Absent pulses or Foot deformity Neuropathy & absent pulses +/ deformity or previous ulceration episode, now healed. Relative Risk of ulceration is 80 times the risk for those in green box Superficial Ulceration and skin fissures, no evidence of infection. Or? Charcot s warm swollen foot but no ulcer and no architectural distortion present The Infected Foot Stage 4 Where the patient is systemically well and no necrotic or devitalised tissue is visible. Or with new Charcot s when architectural distortion already present The Infected Foot Stage 5 Patient is systemically unwell Devitalised tissue present Necrosis Visible/protruding bone Gangrene Managed by GP Practice Patient education leaflet Annual review Managed by GP & Podiatry Patient education leaflet Review interval determined by podiatrist Managed by Podiatry & Orthotics intensively: Ring Fax Urgent Podiatry Referral If Charcot s suspected, patient to minimise weight bearing on affected foot: Ring Fax Same Day Urgent Podiatric referral OR Diabetic Foot Clinic Ring OR Dr Mulcahy/Horndon Ward or X 1952 Refer to Hospital MDT Foot Team Dr Mulcahy Ring OR Horndon Ward ext Diabetic Foot Pathway - Brentwood

9 8. Rapid Advice Service for Haematology (RASH) GP identifies a patient with a haematological abnormality Refer to RASH Referral assessed by Consultant Haematologist Electronic reply within two working days with advice on: Likely diagnosis (es). Further investigation and management in the community. Whether a formal secondary care haematology referral is necessary. Re-referral for further advice on any subsequent investigation interpretation available. Inclusion Criteria Anaemia (Hb >8). Polycythaemia (Hct >47% F; >50% M). Isolated macrocytosis (MCV >100) Leucocytosis & lymphocytosis. Eosinophilia. Leucopenia, neutropenia & lymphopenia. Thrombocytosis & thrombocytopenia. Haematinic abnormalities. Raised globulins. Low concentration paraproteins Anticoagulation & thrombosis problems. Easy bruising. Accessing the RASH Service Exclusion Criteria Suspected: Leukaemias.* Lymphomas. Myeloma. Severe or multiple cytopenias. Refer direct to secondary care either urgently or via 2WW. *Could refer early CLL to RASH. For Basildon, Brentwood, Billericay & Wickford Localities Right click on communicaions. Click on communications wizard. Click SystmOne user. Select Brentwood Day Hospital. Click on + sign, scroll down and select Dr. Andy Hughes. Select send electronic message. Type in referral question. Click send. Make sure there is shared care granted (Go to administration; R. click shared care; select new share). 8. Rapid Advice Service for Haematology (RASH)

10 9. MSK / Tier II Inclusion Criteria All Trauma and Orthopaedics, Pain Management and Rheumatology referrals that do not fit into the below exclusions should be referred to Tier II. Exclusion Criteria Direct referral to secondary care by GP is appropriate for: Red Flags Urgent Suspicion of systematic inflammatory disease requiring medical management, e.g. morning stiffness present for > 30 minutes or more than 6/52 Refer directly to rheumatology Suspicion of serious pathology (malignancy, infection), i.e. general malaise, weight loss, night sweats, loss of appetite Refer directly to secondary care Signs of cord compression/cauda equina syndrome, ie bilateral leg pain, bladder/bowel frequency or retention, saddle anaesthesia, gait disturbance, pins & needles, numbness, or worsening neurological symptoms. Refer directly to neurosurgery/orthopaedics Suspicion of recent fracture requiring intervention Refer directly to orthopaedics Post-Surgical Problems Acute Trauma Previously assessed patient requests surgery Children (Any under 16 years of age should be referred to secondary care (paediatrics) Accessing MSK/ Tier 2 For Basildon, Brentwood, Billericay & Wickford Localities Complete a referral form and send to Tier II with or without a referral letter by fax to or it to swe-pct.tierii-msk@nhs.net You can also send a referral via Choose & Book. Queries MSK / Tier II

11 10. Community Ophthalmology Inclusion Criteria Persistent/chronic or unexplained red eyes Asymptomatic incidental eye lesions e.g. on retina, cornea or conjunctive usually noted by opticians including naevi, cysts, etc. Blepharitis including Acne rosacea Epiphora (watery eyes) Eyelid lesions Cysts, Chalazion, Trichiasis etc. Dry eyes Iritis recurrent/acute including Shingles Keratitis Floaters/flashes (Photopsias) Dry Macular degeneration (a) Pressure checks including gonioscopy of eye angles (b) Pressure checks with Goldman s and Pachymetry for corneal thickness. Unexplained eye symptoms e.g. pain, following assessment by GP/Opticians/OPSIs, or for 2nd opinion. Visual symptoms including transient visual loss Screening for systemic condition with eye manifestations, ocular side effect of drugs and patient unsuitable for diabetic photography screening Exclusion Criteria Age 5 years or less Squints, Glaucoma Patients for intraocular surgery e.g. Cataracts Patients requiring glasses prescription Accessing the Community Ophthalmology Service For Basildon, Brentwood, Billericay & Wickford Localities Referrals to the service can be by fax , via Choose & Book or letter. Urgent cases and advice only, can be obtained by telephoning / Community Ophthalmology

12 11. Community Dermatology Accessing Community Dermatology For Basildon, Brentwood, Billericay & Wickford Localities Referrals to this service should be sent by writing to: Dr U Buhari, Community Dermatology clinic, Mayflower Community Hospital, Blunts Wall Road, Billericay, Essex, CM12 9SA Tel: Fax: Community Dermatology