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Embrace care update
18 November 2020

Contents


Prioritising Embrace

Focusing on our vision

Despite the COVID-19 second wave and many colleagues busy preparing for the vaccine and winter planning, the Embrace programme is making headway. We want to thank colleagues who continue to prioritise Embrace into their daily schedules and for their ongoing commitment to the programme.

The fundamental vision for Embrace is never more important for Cornwall than now. Health and care colleagues working together to develop new ways of working, ensuring people receive the right care, in the right place at the right time.

Right care, right place, right time

Community intervention offer

A trial team has started to work differently in the North Kerrier Primary Care Network where they have agreed to leave their lanyards at the door. Bringing together a broad range of skills to work as one team to manage the needs of the local population and deliver a more community focussed offer. Initially this team includes colleagues from Corcare’s STEPs service, HomeFirst, advanced nurse practitioners and adult social care. The team are getting to know each other and working together to:
  • test new ways of working focused on providing the right care, in the right place, at the right time
  • reduce the amount of duplication that exists between organisations/teams
  • deliver the urgent community response (UCR) targets: 2 hour urgent response and 2 day reablement response
  • enable a primary care network focused use of local resources to meet demand
  • develop a single performance framework to measure the impact of the test and trial phase
These steps will allow for a more person centred approach and improve the speed with which people are seen.

Temporary bedded care

The trial at Helston Community Hospital is going well. Data is being collated from daily huddles to understand the reasons for delays to the next step in a patient journey. The team have also incorporated extra questions into their daily routine with a clear mind set of ‘Why not home? Why not today?’
 
Thank you to Helston Hospital for your continued hard work and support!

Primary care network / integrated care area development

The agreed priority projects in each integrated care area having identified local challenges are making progress here is an update from each team:
 

West Cornwall integrated care area

We are making progress with our daily 15 minute huddle with Helston Medical Centre and the wider multidisciplinary teams consisting of community nurses, matrons, social workers, therapists and Home First along with a GP. Mental health and voluntary teams are also soon to be included. The purpose for the huddle is:

  •  a quick rapid round of people we are worried about on the day
  •  to flag acute issues that will need response on the same day, or cases that require coordination and sharing of information, plans and risk
  • identifying who those people may be known to and the best person to contact them and find quick solutions

If the same individuals keep coming up daily, then these cases are escalated for discussion at the structured multidisciplinary team meeting.
 
This is a learning experience so each day we review who else we may need to join, and if we are getting stuck on any issues. It’s early days, but so far it’s going very well, and we're finding solutions, with the right person, with the right skills, picking up the actions.
 
As part of the community intervention offer trial, we are commencing huddles next Monday, and these will follow the same format.
 

North and east Cornwall integrated care area

Our project is to carry out a test and learn in Liskeard around non urgent home visiting for patients with chronic long term illness. We want to ensure the right skill set supports a person to reduce duplication and case escalation.
 
We are reviewing data to ensure that we are aligning our project to the most appropriate patient cohort. Then we will be in a better position to ensure that we have the right project team in place.
 
We have engaged with the system stakeholders and have had our first project meeting. This was a really positive exercise in ensuring that we move forward as a system.
 

Central Cornwall integrated care area

Our project is focussed on wound care at the weekends as this service is currently not commissioned. Our aim is to reduce pressure on minor injury units and emergency departments at weekends.
 
The project team is now up and running with our clinical lead coming from tissue viability. data leads at Royal Cornwall Hospital and Cornwall Partnership Foundation Trust are pulling together figures for analysis. Once we have all the data we will conduct case reviews, and combined with the data we hope this will define a possible solution for wound care at weekends. We still remain hopeful COVID will not delay the project.

Microsoft Teams Embrace forum

There is now an Embrace forum on Microsoft Teams. This provides a route for you to ask questions about Embrace and share information with colleagues across the system. A number of people will be invited to join who already work within Embrace workstreams. If you would like to be added on Teams please get in touch with the Embrace team.
Get in touch with the Embrace team

Forward the sign up form link to colleagues so they can receive weekly emails about the Embrace programme direct to their inbox.
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