Deliver an integrated model of Community Services with right-sized capacity, underpinned by effective urgent response elements and streamlined emergency care pathways to ensure timely, coordinated support
The primary focus of High Impact Change Model: reducing preventable admissions is to reduce admissions to hospitals by remaining in or returning to the community.
D1: An integrated model of Community Services with right-sized capacity
- Community operating models are complex, including services extending across proactive, planned, and urgent care – both preventing and responding to crises. For links to national guidance on specific elements of the model see Suggested Actions section below.
- The size and nature of these elements can be assessed via population needs analysis, including JSNAs and the Core20Plus5 method to address health inequalities. Movement of people between services at the right time in their care pathway should be part of planning capacity and response levels.
- Avoidable admissions can occur when acute care becomes the “easiest option” and the ideal pathway is not followed due to e.g. complexity, risk aversion or mistrust. Intermediate care and Urgent Response services need to be accessible both from the community and to turn around people following an acute attendance. This requires knowledge of, and referral to, relevant community services within the acute front door. This is particularly relevant when geographical proximity of an acute site drives walk-in activity, by-passing opportunities for triage and support in the community.
- Integration of these services must exist at a practical process level, as well as any organisational structural change – see the Suggested Actions section below for more on practical integration considerations.
D2: Effective Urgent Response Elements and Emergency Pathways
- In the past three to four years, there has been notable progress in urgent community response services, focusing on Rapid Response nursing and other services that can respond within two hours. Urgent response elements also help reduce attendance and ambulance conveyance; understanding service priorities is vital when capacity is limited.
- Evidence-based actions related to admission avoidance from NHS planning guidance in recent years include: (Link)
- Increasing volume and consistency of referrals to improve patient care, ease pressure on ambulance services, and avoid admission.
- Standardising and improving care across all virtual ward services to improve the level of care to prevent admission to hospital, and improve discharge.
- Reducing variation in Same Day Emergency Care (SDEC) Provision for at least 12 hours a day, 7 days a week
- Reducing variation in acute frailty service provision. Improving recognition of cases that could benefit from specific frailty services and ensuring referrals to avoid admission.
- Driving standardisation of urgent integrated care coordination which will facilitate whole system management of patients into the right care setting, with the right clinician or team, at the right time.