What was the issue you were addressing or working on?
Reducing emergency admissions for people with long term conditions (with focus on COPD, Heart Failure, Diabetes, Recurrent UTI/Infection & Falls).
What you did?
The Community Ward model is a method of delivered targeted case management in the community setting, for patients with complex long-term conditions who are at most risk of unplanned hospital admissions.
The NHS Ayrshire and Arran Community Ward was established August 2012 as a primary and community care response to Reshaping Care for Older People.
- Comprises of three teams: East, North and South
- Each team consists of GP, Advanced Nurse Practitioner and Community Ward Administrator
- Each team covers approx 50,000 patient population
- Each team/ward cares for up to 100 patients
Community Ward GPs and Advanced Nurse Practitoners provide tailored care package for patients with long term conditions in the home setting. CW team liase with variety of partner services from primary & secondary care as well as social care department and other external organisations (e.g Care Homes).
What were the outcomes - benefits or otherwise?
The Community Ward is subject to three evaluation methods. These are logic model outcomes evaluation, led by public health, qualitative evaluation using three different patient data capture methods, clinician and staff evaluation. In addition an economic modelling and interim evaluation has been completed and the results of both reports are available. Summary information from these is available here.
Contacts - to find out more
Kathleen McGuire, Kathleen.McGuire@aapct.scot.nhs.uk 01563 826739