SaHF DMBC Volume 1 Edition 1.1.pdf - Shaping a healthier future

Figure 8.4: New and enhanced roles supporting out of hospital delivery
Case management
Home based rapid response
Shared across both
▪
Patient / Patient /
User User
Self-manages ▪ Self-manages care with care support with support
from health from health and social and social care care
professionals professionals and carers and carers
Carers Carers
▪ ▪
Provides psychological and/or
personal care and support to
individuals
▪ Act as first point of contact for very high risk individuals
▪ Act as first point of contact for very high risk individuals
Clinical
and carers
Clinical case
and carers ▪ Perform holistic assessments and initial diagnostics of
case managers ▪ Perform individuals‟ holistic assessments health and and social initial care diagnostics needs of
managers individuals‟ ▪ Co-create health and care social plan with care individuals needs and carers, using lowlevel
care cognitive plan with behavioural individuals therapy and carers, techniques, using e.g., low-
▪ Co-create
level cognitive motivational behavioural interviewing therapy techniques, e.g.,
motivational ▪ Provide interviewing on-going care and monitoring, drawing in
▪ Provide on-going specialist care input and as needed monitoring, drawing in
specialist input as needed
▪ Provides psychological and/or personal care and
Community ▪ Provides support psychological to individuals and/or personal care and
Community Health support to individuals
Health
Worker
Worker
▪ Provide supervision to nurses/case managers for
CBT Mental motivational interviewing and deliver higher level CBT
Health ▪ Provide supervision to nurses/case managers for
CBT Mental Supervisor motivational interviewing and deliver higher level CBT
Health
Supervisor
Intensive
Intensive
Home Care
Home Clinicians Care
Clinicians (Nurses &
(Nurses Therapists) &
Therapists)
Intensive
Intensive Home Care
Home
Administrator
Care
Administrator
Handyman
Handyman
▪ Perform face to face assessment and rapid
▪ Perform face to face assessment and rapid
interventions at individual‟s home for defined
interventions period at individual‟s home for defined
▪ period Provide on-going care and monitoring,
▪ Provide support on-going reablement care or and care monitoring,
of the dying,
support including reablement using other or team care members of the dying, as
including appropriate using other team members as
▪ appropriate Provide clinical support for HSCC for
▪ Provide determining clinical appropriate support for response HSCC for referral
determining appropriate response or referral
▪ Act as a single point of
▪ Act access as a single for referrers, point of taking calls from GPs,
access ambulance for referrers, service, and taking carers calls (in from the GPs, case of
ambulance
palliative care)
service, and carers (in the case of
▪ Refer individuals to rapid response team or to
palliative care)
most suitable provider
▪ Refer individuals to rapid response team or to
▪ most Perform suitable specific provider moving and handling tasks,
installation of equipment, etc. as needed by
▪ Perform team to specific support moving the patient and / user handling tasks,
installation of equipment, etc. as needed by
team to support the patient / user
Health &
Social Care ▪
Health & Co-ordinator
Social Care
Co-ordinator ▪
Social
Worker
Social
Worker▪
▪
▪ Coordinate health and social care packages according to
the care plan agreed by the case manager, individual and
Coordinate carers; health Support and social individuals‟ care packages maintenance according of goals to
the care ▪ Coordinate plan agreed early by the supported case manager, discharge individual from acute and to home
carers; Support
and on-going
individuals‟
care prior
maintenance
to discharge
of
from
goals
rapid response,
including liaising with primary care team, individual, carers,
Coordinate early supported discharge from acute to home
and social care
and on-going care prior to discharge from rapid response,
including liaising with primary care team, individual, carers,
and social
▪ Perform specialist assessments / interventions when
care
requested by Case Manager or Health and Social Care
Coordinator
Perform ▪ Provides specialist specialist assessments input into / interventions care plans when
requested by Case Manager or Health and Social Care
Coordinator
Provides specialist input into care plans
▪ Perform on-going health care, reablement, and
Health &
personal care and monitoring, including support
Social Care ▪ Perform mental on-going health health care, reablement, and
Health Worker & ▪ personal Conduct care observations and monitoring, and report including deviations support
Social Care
▪
for
Support
mental
equipping
health
and liaise with HSCC to
secure health, social care and voluntary services
Worker ▪ Conduct observations and report deviations
when unable to provide directly
▪ Support equipping and liaise with HSCC to
secure health, social care and voluntary services
▪ Provides medical cover to team and specialist
Community when
input
unable to provide directly
Health
▪ Works directly with case managers to monitor
Medic ▪ Provides medical cover to team and specialist
Community
very-high risk LTC individuals
(sessions) input
Health
▪ Works directly with case managers to monitor
Medic
very-high risk LTC individuals
(sessions)
1: It is assumed that the teams will in addition have access to condition-specific specialist opinion, and to regular care already provided by in the
community, e.g., primary care, pharmacist support as needed
1: It is assumed that the teams will in addition have access to condition-specific specialist opinion, and to regular care already provided by in the
community, e.g., primary care, pharmacist support as needed
8a. Development of out of hospital plans in NW London 228