The Trust has tested new ways of working and made a number of improvements over the past two years to community services in northern Devon, including the Torrington area.
This has been made possible with the injection of special funding – known as Section 256 – from Devon County Council and money from the Northern, Eastern and Western Devon Clinical Commissioning Group.
The investment project, called Optimising Community Services (OCS), has been tailored to meet the needs of the local community.
The expansion of the community therapy and nursing teams, as well as the development of strength and balance classes to assist people at risk of a fall, are highlighted on other pages in this website section.
The investment has also led to a number of other developments in northern Devon, aimed at assisting people to live safely and independently in their own homes.
- Community nurses from the Trust provide training to staff in care homes to proactively reduce the number of avoidable admissions to hospital. The training focuses on three of the most common causes of admission – diabetes, urinary tract infections and tissue viability (wounds). Training programmes have taken place in 15 care homes, with about 175 staff benefitting.
- Dedicated discharge co-ordinators have been recruited to cover all five community hospitals in Northern Devon. They support patients with complex needs to ensure they receive a timely discharge from hospital to their optimum place of safety.
- The Trust has appointed cluster pharmacists to increase medication reviews for people identified as at risk by their GP and to improve the pathway between primary and secondary care.
- The Trust has extended its Pathfinder service, based at North Devon District Hospital. The service acts as a single point of referral for the inpatient wards and the emergency department, to prevent avoidable admissions and enable timely discharge. The team also provides a rapid response service for people living in the Barnstaple area.
- The Trust has secured access to recuperative care beds in nursing homes for people who require a time-limited period of 24-hour care but do not need an admission to hospital or a long-term placement in a care home. This service is provided across the Trust’s Northern and Eastern areas and helps to prevent avoidable admissions.
- The voluntary sector has become more involved in discharge planning, such as befriending support to enable a person to settle back at home and regain confidence after being in hospital. Other voluntary activities include shopping, welfare checks, support for carers and escorting people to appointments.
- The Trust’s specialist palliative care team is now integrated with services at North Devon Hospice to support the wishes of individual patients and their families, in line with the national End of Life Care Strategy. This means better coordination of care and improved quality of life for people, via a single 24/7 service, with far fewer avoidable admissions. District nurses, GPs and care homes are also closely involved.
Care closer to home
Where: Honiton, Ottery St Mary, Seaton, Axminster and Sidmouth
This project is about ensuring that patients can be cared for as near as possible to their own home: in a community hospital rather than the RD&E, and at home rather than in a community hospital.
A single point of access via a ‘red phone’ can be used by GPs and other professionals to trigger a two-hour response by nursing and occupational therapy staff to assess patients. Further staff were recruited to increase capacity in summer 2012.
As a result, home adaptations and domiciliary services can be lined up very quickly to support people outside hospital, speeding up and avoiding admissions.
Hospital at Home
Where: Exmouth and Budleigh Salterton
The Hospital at Home project provides active treatment by health and social care staff, for a limited period of time, in the homes of patients whose condition would otherwise call for in-patient admission. It also enables earlier discharge from the RD&E and the two community hospitals. It covers people living in care homes.
Patients are either referred directly by their GP or are transferred from the RD&E following screening by the care of the elderly consultant who oversees the team.
The combined team includes nurses, therapists, care agencies, and can call for input from older people’s mental health services. Together, they provide 24/7 care for up to 21 days, using shared as well as specialist skills.
A single point of access triggers assessment at home within two hours for patients who might otherwise need hospital admission, and four hours for those coming out of hospital. Care is provided within a virtual ward, using an electronic whiteboard and daily ‘ward rounds’, with weekly multi-discplinary team meetings led by the geriatrician.
Mid Devon Pathways project
Where: Cullompton, Tiverton, Crediton, Moretonhampstead and Okehampton
This project was developed with staff and GPs to prevent hospital admission and promote timely discharge, using defined pathways to make sure patients were cared for at home wherever possible.
It is based around a Rapid Intervention Centre that takes GP calls and completes initial assessment forms for the local complex care teams. Each CCT Co-ordinator then has access to a rapid response team that picks up all urgent cases each day.
The team also works closely with hospital discharge facilitators covering Tiverton, Crediton, Moretonhampstead and Okehampton community hospitals and trainee assistant practitioners.