Adult community services West Hertfordshire CLCH Clinical Pathways Version 1 October 2019 1 Contents Message from Andrew Ridley, Chief Executive at CLCH ............................................................... 6 About CLCH’s Clinical Pathways .................................................................................................. 6 REFERRAL AND CONTACT DETAILS .............................................................................................. 7 BLADDER & BOWEL .................................................................................................................... 8 CLCH MODEL .................................................................................................................................... 8 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................... 9 PATIENT FLOW ............................................................................................................................... 10 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 11 LOCATIONS OF SERVICES ............................................................................................................... 11 TIMESCALES AND MILESTONES...................................................................................................... 11 CARDIAC REHABILITATION ....................................................................................................... 12 CLCH MODEL .................................................................................................................................. 12 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 12 PATIENT FLOW ............................................................................................................................... 13 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 14 LOCATIONS OF SERVICES ............................................................................................................... 14 TIMESCALES AND MILESTONES...................................................................................................... 14 COMMUNITY BEDS - NEURO/STROKE AND GENERAL REHAB ..................................................... 15 CLCH MODEL .................................................................................................................................. 15 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 17 PATIENT FLOW ............................................................................................................................... 18 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 19 LOCATIONS OF SERVICES ............................................................................................................... 20 TIMESCALES AND MILESTONES...................................................................................................... 20 COMMUNITY FRAILTY AND FALLS ............................................................................................. 21 CLCH MODEL .................................................................................................................................. 21 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 22 PATIENT FLOW ............................................................................................................................... 23 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 24 LOCATIONS OF SERVICES ............................................................................................................... 24 TIMESCALES AND MILESTONES...................................................................................................... 24 COMMUNITY NEURO REHAB .................................................................................................... 25 CLCH MODEL .................................................................................................................................. 25 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 26 PATIENT FLOW ............................................................................................................................... 27 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 28 2 LOCATIONS OF SERVICES ............................................................................................................... 28 TIMESCALES AND MILESTONES...................................................................................................... 28 COMPLEX CASE MANAGEMENT ................................................................................................ 29 CLCH MODEL .................................................................................................................................. 29 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 31 PATIENT FLOW ............................................................................................................................... 32 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 33 LOCATIONS OF SERVICES ............................................................................................................... 33 TIMESCALES AND MILESTONES...................................................................................................... 33 DISCHARGE TO ASSESS – PATHWAY 1 (STILL IN DEVELOPMENT) ............................................... 34 CLCH MODEL .................................................................................................................................. 34 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 35 PATIENT FLOW ............................................................................................................................... 36 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 37 LOCATIONS OF SERVICES ............................................................................................................... 37 TIMESCALES AND MILESTONES...................................................................................................... 37 CHRONIC HEART FAILURE ......................................................................................................... 38 CLCH MODEL .................................................................................................................................. 38 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 38 PATIENT FLOW ............................................................................................................................... 39 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 40 LOCATIONS OF SERVICES ............................................................................................................... 40 TIMESCALES AND MILESTONES...................................................................................................... 40 LEG ULCER SERVICE .................................................................................................................. 41 HERTS ONE MODEL ........................................................................................................................ 41 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 42 PATIENT FLOW ............................................................................................................................... 43 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 44 LOCATIONS OF SERVICES ............................................................................................................... 44 TIMESCALES AND MILESTONES...................................................................................................... 44 LYMPHOEDEMA CLINICAL PATHWAY ........................................................................................ 48 CLCH MODEL .................................................................................................................................. 48 INTERDEPENDENCE WITH OTHER SERVICES .................................................................................. 49 PATIENT FLOW ............................................................................................................................... 50 ACCEPTANCE AND EXCLUSIONS ..................................................................................................... 51 LOCATIONS OF SERVICES ..............................................................................................................