Enhance general access and navigation through a flexible, resilient network of well-connected services that adapt to individual and system needs
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.
E1: Improved general access and navigation
- Ensure referral pathways are robust from major access routes including 111, 999, primary care referrals, social care front door, and acute triage pathways. Focus on staff knowledge and trust of community options, and the ease and timely nature of referral processes. Underpin this with digital tools that are up to date and easy to navigate.
- Create clear referral pathways between ambulance services, and local urgent care, ensuring staff are informed, aware and adhering to referral pathways. A variety of single access point models exist to support clinical triage and local service navigation.
- Provide the workforce with the technology that enables them to communicate and collaborate with other health and care colleagues. Enable a transfer of information between settings that follows the patient, increasing continuity of care.
E2: Flexibility and resilience of well-connected services
- Conduct audits on avoidable admissions to identify gaps in referral pathways and update community criteria as needed, as well as developing new services or adjusting capacity of existing services.
- Plan operational capacity based on local demand patterns, efficient rota scheduling and planning follow-ups in low demand timeslots.
- Manage interfaces and dependencies between services - identifying where for example urgent response resource is being used for follow-up activity that could be better delivered via a different service.
- A joined up journey across services is enabled by activities such as using a shared care record, goals and care plans moving from service to service to reduce duplication, and effective communication with the individual and their support network throughout.
- Many high-risk individuals are already in contact with the system – on caseloads such as with district nursing, Neighbourhood MDT, or social care package - leverage existing contacts to offer better pro-active support. Also if they do escalate what opportunities exist to link with their existing service to provide continuity and familiarity?
- As data and digital tools evolve, systems will provide a more integrated view of capacity and individual outcomes, aiding future pathway design and real-time decision-making.