PCN Forum is a daily call in each of the PCNs with representation from senior case manager, Case Manager, Senior HSCA and at least one District nursing team. Senior staff in the Forum discuss most complex patients from the PCN (i.e. those at high risk of hospital admission) Capacity & demand.
I case manage the same complex patients the District Nurses visit...
Integrated Community Teams
I refer patients to District Nurses and toMy Care My May
Could we work more closely and effectively together?
I often have to repeat my story...wish you would respond better to my care needs...
Co design workshops (June-July 19)
Senior staff from both services would huddle to discuss patients and service needs and plan for the day
Great, though we'll need to develop a procedure to make it happen
Sounds feasible...a joint call should help to share our resources and knowledge, and to reduce duplication of assessments, tasks and visits
Good morning, this is Jane from the DN team. No issues from last night.I received a GP referral for bloods for Mr Kay but the allocated nurse has no capacity and she must urgently change Mrs Katia's catheter today
Forum trial (August 19)
Hi, this is Martin, Senior Health & Social Care Assistant. Happy to take the bloods as i was going to see Mr Kay anyway.
Very helpful Martin. We also need to visit a new patient, Mrs Joan, for an assesment...
CLCH led the development of the Integrated Community Team starting with the integration of District Nurses and My Care My Way services within the Primary Care Networks (PCNs)
Forum trial 2 (August 19)
..oh, so you know Mrs Joan...this is Angela, Senior Case Manager. Joan is frail and has been diagnosed with x. I have capacity to assess her tomorrow and i'll feedback on Monday.
Staff from both services attended 5 co-design workshops and worked on the development of the West London PCN Forum (a call huddle) and it's supporting documents (e.g. terms of reference, agenda, roles and responsibilities of the Forum Lead)
It is important we discuss the patients most at risk of hospital admission and manage planned care better using SystmOne
We are not clear how to escalate capacity issues and record our discussions and actions
Forum Champions (Senior Case Managers and District Nurses) led the daily calls during the 4 week trial period....
Throughout the trial 5 Forums took place daily across the 5 PCNs from Monday to Friday at 9.30am
Thank you Angela that will be even better for Mrs Joan.Which patient should we discuss next?
In addition, stakeholders and Champions discussed their concerns at weekly and follow up feedback sessions.
The survey we did showed that the Forum has improved sharing of information and reduced duplication but we need to test some processes further and develop a system to identify patients at risk