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Acute GP pathway for admission avoidance

Behind STRATA referrals sit the ICA Transfer of Care Hubs (IToCH). These are contactable by phone for front door services for urgent referrals, and by referrers (not public) to check on progress of their referral.

There are 3 IToCH services in Cornwall

  • North & East IToCH -  01208 834569

  • Central IToCH -            01726 873248

  • West IToCH -                01872 326711

IToCH’s provide local management and co-ordination of referrals 8-8, 7 days a week from:

  • Primary care (GPs and Kernow Health CIC), SWASFT, NHS 111 and other community partners seeking support to keep someone in their own home and/or avoid admission to acute and community hospital. The IToCH will help professionals arrange the right care for urgent and non-urgent referrals, helping to prevent hospital admissions and effectively manage long-term conditions in the community. This includes community 2-hour urgent crisis response and 48-hour reablement provision (See Community Urgent Crisis Response service specification)

  • Acute and community hospitals to support someone leave a hospital setting

  • Care homes to support transfer to another care setting

  • Care homes referring for urgent and routine care and support 

 

Each IToCH manages referrals for the people resident in its Integrated Care Area (ICA) geographical footprint. Registration with a GP is not required, but in most instances the IToCH’s will be managing referrals for people registered to GPs within the ICA.

IToCH’s provide an integrated, personalised service offer combining the expertise and capacity from Cornwall Foundation Trust (CFT) adult community services, Cornwall Council Adult Social Care, the Voluntary sector, and other partners.

 

The primary functions of the IToCH’s are to

  • Receive, triage and progress referrals (electronic and telephone) with the aim of ensuring that the most effective and cost-effective outcomes are achieved, while at the same time respecting a persons’ right to choose

  • Work in both a multi-disciplinary and interdisciplinary way to develop timely and person-centred plans for individuals based on the principles of “no place like home” recognising the complexities of maintaining independence and real-life positive risk taking

  • Support discharges to happen safely through close working with the Hospitals/wards, quality assurance of information and practical support

 

The service is responsible for

  • Providing a single access point for referrers and robust referral mechanism. 

  • Communicating service details to referrers including how, when and why to refer.

  • Ensuring an accurate Directory of Service page

  • Accepting telephone referrals (clinician to clinician conversation) for requests for 2-hour urgent crisis response, from Emergency Departments requesting same day response or requests for support from the Care Home Support Team

  • Completing quality reviews of referrals to ensure all required information to enable safe and effective discharge has been provided

  • Securing additional information as required with the principle that minimal calls/emails should be sent to referrers and wherever possible information should be sought from existing and available information systems.  This will require people in the service to have, at a minimum, access to organisational systems including:

  • Nervecentre (RCHT)

  • RIO (CFT)

  • Mosaic (Adult Social Care)

  • Broadcare

  • Maxims

  • Triaging all referrals received and documenting the rationale for triage decisions and outcomes appropriately 

  • Post triage - referring to and securing the right service/capacity for each triaged referral from the collective suite of community services in the relevant geography including advanced clinical assessments within 2 hours for people needing an urgent crisis response, Clinical Assessment and Treatment Units (CATUs), virtual wards, provision of equipment, access to Technology Enabled Care (TEC), community nursing, community therapy, social care support, IV antibiotics, reablement, voluntary sector support, social prescribers,  community hospital and care home beds. 

  • Allocating resources to progress referrals to ensure care and support is provided at the earliest opportunity

  • Closing referrals on the referral management system at the right time

  • Updating appropriate systems (e.g., Strata, RiO, Mosaic, Nervecentre – not an exhaustive list) on the status of referral triage, progress, and outcomes

  • Providing management reporting on referral volumes, triaged outcomes, referral status

 

Service Exclusions

·      Referrals from GPs seeking acute hospital admission – these should be referred to the Acute GP service

·      Management of referrals for end-of-life community care. These are managed by Marie Curie

·      Stroke pathway referrals from acute to community stroke wards.

·      Adult Mental Health referrals

·      Public direct access.  Public access to the service in other circumstances will be via NHS 111 or GP referrals for community support

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