ROYAL WOLVERHAMPTON NHS TRUST

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ROYAL WOLVERHAMPTON NHS TRUST . ADULT COMMUNITY SERVICES LONG 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 - PowerPoint PPT Presentation

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<p>PowerPoint Presentation</p> <p>ROYAL WOLVERHAMPTONNHS TRUST ADULT COMMUNITY SERVICESLONG TERM CONDITIONS</p> <p>Patient JourneyPatient 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 communityPatient is referred to H@H for IV managementH@H, following their assessment, discuss the patient with the Community Matron during the virtual ward MDTCommunity Matron case manages the patient using evidence based practice and Tele-health. Patient is discussed at the respiratory MDT.</p> <p>2Virtual Ward ModelConcept from Hospital Wards3 Wards per Locality made up from:Community MatronsDistrict NursesH@HContinenceWound careBeds in own home/residential homes/resource centresTeams aligned to General PracticesPatients cased managed by MDT using Clinical PathwaysVarying levels of care - dependent on patient needSupported by Healthy Lifestyles</p> <p>WUCTASACUTE SERVICESUrgent Out-Patient AppointmentE.g HOT ClinicConsultant advice via Conference callsAdmission to Acute Medical Unit</p> <p>Access to DiagnosticsTo Facilitate Discharge (including Acute step down bedsCommunity Integrated Care Service(CICT)West Midlands Ambulance ServiceAdult Community ServicesGPs</p> <p>Hospital @HomeExperienced team of nurses who manage the following conditions in the community:-IV therapyCOPD exacerbation CellulitisDVTESBLRe-site IVs</p> <p>Community MatronsHighly trained nurses who assess, diagnose and treat patients holisticallyIdentify caseload utilising predictive risk data Proactive case management approachUser of IT systems: Clinical web portal, CDS, Tele-health, Risk Stratification software.Personalised Management Plans Collaborative working e.g GPs, consultants, therapy services</p> <p>TELE-HEALTHPatient Aims:To support and promote independenceTo enable recognition of worsening conditionReinforces personalised management plansImprove quality of lifeBuild confidence in self managing their LTCClinician Aims:Trend monitoringEarly response in the event of deterioration to enable appropriate interventionMedicine management eg titration of current therapy or initiating new treatments</p> <p>Each patient is assessed for suitability for Tele-health on acceptance to the caseload with the aim of improving quality and the patient experience</p>

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