ROYAL WOLVERHAMPTONNHS TRUST

ADULT COMMUNITY SERVICESLONG TERM CONDITIONS

Patient Journey• Patient has sub optimal control of COPD, and has

developed cellulitis unresponsive to oral antibiotics.• GP assesses and telephones WUCTAS for advice on

management options in the community• Patient is referred to H@H for IV management• H@H, following their assessment, discuss the patient

with the Community Matron during the virtual ward MDT• Community Matron case manages the patient using

evidence based practice and Tele-health. • Patient is discussed at the respiratory MDT.

Virtual Ward Model• Concept from Hospital Wards• 3 Wards per Locality made up from:

– Community Matrons– District Nurses– H@H– Continence– Wound care

• Beds in own home/residential homes/resource centres• Teams aligned to General Practices• Patients cased managed by MDT using Clinical Pathways• Varying levels of care - dependent on patient need• Supported by Healthy Lifestyles

WUCTAS

ACUTE SERVICES Urgent Out-Patient Appointment

E.g HOT Clinic

Consultant advice via Conference calls

Admission to Acute Medical Unit

Access to Diagnostics

To Facilitate Discharge (including Acute step down beds

Community Integrated Care Service

(CICT)West Midlands

Ambulance Service

Adult Community Services

GP’s

Hospital @Home

Experienced team of nurses who manage the following conditions in the community:-• IV therapy• COPD exacerbation • Cellulitis• DVT• ESBL• Re-site IV’s

Community Matrons

• Highly trained nurses who assess, diagnose and treat patients holistically

• Identify caseload utilising predictive risk data • Proactive case management approach• User of IT systems: Clinical web portal, CDS, Tele-

health, Risk Stratification software.• Personalised Management Plans • Collaborative working e.g GP’s, consultants,

therapy services

TELE-HEALTHPatient Aims:• To support and promote independence• To enable recognition of worsening condition• Reinforces personalised management plans• Improve quality of life• Build confidence in self managing their LTCClinician Aims:• Trend monitoring• Early response in the event of deterioration to enable appropriate

intervention• Medicine management eg titration of current therapy or initiating new

treatments

Each patient is assessed for suitability for Tele-health on acceptance to the caseload with the aim of improving quality and the patient experience