Jan 2023

COMMUNITY FLOW is a service that is delivered by the Trust and now forms part of the discharge process for patients. Community Flow can provide all, or some, of the following services following discharge (depending on the levels of need):  

  • Check in at Home – A call within 24 hours of discharge to see how the patient is settling in at home 
  • Settle at Home – Up to 3 visits from a volunteer, can help with things such as essential shopping, collecting prescriptions, setting the heating etc 
  • Support at Home – 1:1 advice, guidance and support for up to 6 weeks from a Community Flow Co-ordinator. This is to try and avoid unnecessary readmission and is based around a ‘What Matters To Me’ conversation with the patient and can include solution focussed support, support to link in with useful organisations and networks within their local community, short-term practical help with things such as cooking, and effective service navigation. 

If you have a patient who may benefit from any of these please identify the patient to the Community Flow service via the attached streamlined referral form and email to rduh.supportathome@nhs.net. 

Dec 2022

To introduce you to Karen Boxall who has joined the Community Flow Team as our Provider Co-ordinator. 

Built into the Community Flow model is the ability for our Community Flow Caseworkers to access a small budget to help patients they are working with.  This budget is able to help speed up discharge or admission avoidance by purchasing unregulated services and support.  The budget is only available for up to 6 weeks – the idea being that if needed the workers will work with the patient to identify a sustainable way their needs can be met beyond this 6 weeks.  The budget works as a tool that the workers can use to compliment/enhance the 1:1 work they do, depending on the individual needs of that patient – it is not a form of ‘grant’ or suchlike that every patient is entitled too.  Karen’s role is to act as a broker to source goods and services which might be needed.   

Her main focus initially will be developing a network of providers – usually self- employed workers or businesses who are able to support us if needed.  She will co-ordinate this, including invoicing etc. 

In line with Adult Social Care, one of the principles of the way we work is that we’ll use an assets/strength based approach – which essentially is that before the budget is accessed, the team will try and find an alternative means of meeting the needs of the patient, either from the assets that exist for that patient within their own networks, or within their local community. There may be times when she, or one of the caseworkers need to reach out to a Community Developer to find out if alternative or complimentary community services and assets exists which may support Community Flow patients – these will most likely be in the VCSE sector – and also if appropriate a CAP meeting can be set up.   

Oct 2022

We have recruited a new member of staff, Nikki Larrington as a full time Community Flow Coordinator. This is the same job role as Tom. Nikki is already in post and her involvement will allow us to have more people on our Community Flow caseload. We also currently have an advert out for another part-time Community Flow Coordinator to assist even further with this. 

We have a lady named Karen starting on the 7th November in the role of Community Flow Provider Coordinator. She will be heavily involved with the purchasing and budgeting side of things. She will coordinate, purchase and record anything associated with the service (using our allocated budget which can be used to spot purchase goods and services for patients following their discharge). 

We are also getting very close to a point where TTVS are able to start running the Ongoing Help at Home Service as part of Community Flow. TTVS have been allocated funding to be able to provide ongoing unregulated care provision. This is funded by the individual or by DCC following an assessment of eligibility. At any point in a patient’s journey through Community Flow, we are able to refer to TTVS for this service. Alternatively, TTVS can accept referrals from the community (to avoid admission to hospital). If a CD would like to refer into this service, they could refer directly to Tom, Nikki and myself and then we will pass this on to TTVS. 

In terms of numbers, we have had 78 referrals since April. With Nikki now in post (and another Community Flow Coordinator post being advertised) we are expecting this to grow significantly. 

To see the number of referrals we have been getting into each section of North Devon since the start of the service, see below: 

  • Barnstaple: 22 
  • Bickington: 1 
  • Bideford: 18 
  • Braunton:8 
  • Chumleigh:1 
  • Combe Martin: 2 
  • Holsworthy: 6 
  • Ilfracombe: 7 
  • Lynton: 2 
  • Merton: 1 
  • Northam: 1 
  • Shebbear:1 
  • South Molton: 5 
  • Torrington: 4 
  • Umberleigh: 3 
  • Westwood Ho: 2 
  • Winkleigh: 2 
  • Woolacombe: 2 
  • NFA: 1