To care for and treat the patient in the
right place with no unnecessary
delay or discomfort, by a responsible
and empowered workforce
SHROPDOC
• Cooperative created in 1996,
• Out of hours primary care services
(PCCs) for 600,000 population,
• Urban areas to extreme rurality,
area over 3,500 sq miles
• 300 local GP members
• 200 other staff including 30 senior
nurses
• Not for Profit organisation
• Clinically led
The Out Of Hours Process
• Process:
– Patients incoming calls
handled by non clinicians
(@150k calls per year),
– GPs and nurses call back
patients for tel. triage,
– Outcome:
• Advice over the telephone,
• Face to face: base
appointment or home visit,
Clinicians,
GPs & nurses
Team leaders and despatchers
• Urgency at various stage
dictates response times,
• Call handlers and triaging
clinicians under one roof
Primary Care Centres
Call handlers
LTC patients: sharing
Information, facilitating access
Sharing information for better care:
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OOH events of care passed onto GP surgeries by 08h00 next working day,
Day time GPs flag LTC (palliative care, mental health condition) patients,
• 10,194 special patient notes,
• Care plans and DNR,
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Emergency Action Plan (partnership with Shropshire local authority) for
adults with learning disabilities,
Facilitate access to vulnerable patients:
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In partnership with VISS: support deaf, and hard-of-hearing patients,
LTC patients: treatment &
monitoring
• In all PCCs: extensive equipment and exhaustive
formulary,
• Syringe drivers,
• Nebulisers,
• Controlled drugs,
• Support national & local initiatives
• Just In Case Box: Palliative Care Patients,
• Initiate Home Oxygen Therapy,
• Telehealth:
• support Community Matrons
• 70 patients using Florence, mobile phones
and devices for physiological measurements,
OOH Shropshire Community
Nurse / SCN
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County wide service,
7 days a week,
1900 to 2400,
Senior community nurses with
specialised training in LTC,
Continuity of care handover
“from and to” day teams,
Can do culture,
Among other interventions:
• Catheterisation,
• Abnormal INR treatment,
• Palliative care,
• COPD,
• Diabetes
Care Coordination Centre
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Single of point access for GPs & other clinicians,
Enabling increasing number of patients to be looked after in their own
homes,
Highly experienced senior nurses with primary care and secondary care
background, and significant LTC knowledge,
Coordinate the most appropriate care pathways for patients,
Facilitate smoother journey throughout primary care and secondary care,
Existing pathways; examples with emphasis on LTC:
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COPD: links with specialised respiratory nurse teams, same day assessment,
Oncology helpline,
Abnormal INR,
Driving pathway developments with emphasis on LTC:
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Diabetes,
Palpitation,
Ascites malignant and non malignant,
Physiotherapy Triage Service
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Referrals direct from GPs
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Telephone Triage – advice, assessment and management
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Self care or onward referral
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Patients gain ownership of problem
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Action whilst on waiting list, not delay
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Experienced working physiotherapist, highly qualified working with Best
Practice Guidance
Other services
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Falls – central hub for referral to Falls Prevention Programme
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Help 2 Quit
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Night Sitting Service
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Immediate Care referral hub
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Lone Worker/Severn Hospice Monitoring
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Weight Management Service
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Step Up/Step Down Bed Management