More than £9 million is being invested over the next five years in adult community care services to support and care for patients closer to home in the Guilford and Waverley area.
It will help support patients to have care and remain at home, avoiding the need for unnecessary admissions to hospital and also making sure they can be helped to return home after any appropriate hospital stay.
There will be an enhanced role for local community hospitals to allow provision for older people living with frailty to be rehabilitated following serious illness.
Over time the Royal Surrey County Hospital NHS Foundation Trust will work towards direct admission into community wards to allow care to be delivered closer to home and prevent the need for patients to be taken to the acute hospital.
It will see the recruitment of additional multidisciplinary staff and will also include the creation of a proactive care hub supported by GPs and Geriatricians. As part of phase one of the mobilization plan this hub will be co-located with the community hospital beds at Milford. The hub will be supported by a dedicated Geriatrician, GP Specialists and an advanced care practitioner.
The investment in a new out of hospital care model over five years from Royal Surrey County Hospital NHS Foundation Trust is the biggest in recent years. It will be reviewed annually and is dependent on the continuing strong financial performance of the Trust, its cost saving programme and national priorities.
It comes as the hospital has seen more than double the national average increase in demand in urgent and emergency care services.
Louise Stead, the Chief Executive at the Trust, said: “This is one of the most significant investments the Trust has made in recent years.
“Our vision is to ensure seamless integrated care continues to be delivered to our patients and this investment is instrumental to this.
“By successfully bridging the gap between the acute hospital and our adult community health services, patients will receive the care they need, care closer to home.
“These plans have been developed by clinicians and are the centrepiece initiative in the newly forming Guildford Waverley Integrated Care Partnership, a partnership across the health, and social care and voluntary sectors including GP colleagues at Procare.
“The success of this work will not only mean improved care in the community but it will also help to keep hospital beds free for those who need the specialist help of our dedicated teams.”
Older people with frailty are already identified and managed by a specialist frailty team working in the Emergency Department at Royal Surrey County Hospital. The Trust is working towards establishing a seven day service and to link much more closely with community hospitals which will see bed numbers return to around 50.
This, along with the Community Coordination Centre at Milford – a one point referral point for General Practitioners, District Nurses and other health professionals – means that the Trust will be able to deliver more integrated care to patients in their own homes.
Mandy Sambrook, Director of Adult Community Health Services, at the Trust, said: “In recent years there has been national recognition of the benefits of supporting older people living with frailty to stay in their home and out of the acute hospital setting.
“With this investment we will enable a more responsive and proactive service and be able to deliver more seamless and holistic care to our patients, with a focus on rehabilitation and maintaining independence for as long as possible.
“By working closely with our colleagues at the hospital we will be able to ensure that patients are receiving the right care, at the right place at the right time.”
A business case to deliver the plans has now been approved by the Board of Royal Surrey County Hospital and work has started to deliver this ahead of winter.
Home First – Case Study
‘Home First’ supports patients who no longer benefit from staying in hospital and enables them to return home for assessment and on-going rehabilitation.
The ‘Home First’ multi-disciplinary teams assess patients on the wards at the Royal Surrey, Haslemere and Milford Community Hospitals to decide who would benefit from this service. The teams include physiotherapists, occupational therapists, nurses and medical professionals.
Patient discharge referrals are then sent to the Community Coordination Centre, based at Milford Community Hospital. These referrals are processed and a discharge date arranged for the patient within 24 hours.
The ‘Home First’ service successfully delivers integrated care, reduces unnecessary hospital stays, and promotes independence.
The added investment into Adult Community Health Services by the Trust will increase capacity of the service and allow more patients to return to their home environment more quickly.
‘Home First’ is a joint venture between the Trust – Acute Hospital and Adult Community Health Services, social services, Guildford Borough Council and Waverley Borough Council.
If you are interested in joining the Royal Surrey family, working in a community rehabilitation role, please contact us via firstname.lastname@example.org.