Terms of Reference for Bridge Virtual Ward MDT meetings
- Introduction
Barts Health NHS Trust in collaboration with Tower Hamlets CCG is working on a number of projects to provide an integrated service in the delivery of care for Children and Young People in Tower Hamlets:
The Bridge community virtual ward: This project aims to facilitate and co-ordinate support in an integrated way across health, education and social care. Through multidisciplinary working, the project will build on The Bridge Community Virtual Ward pilot project in 2014 to provide targeted support to children with complex care needs and high rates of admissions and/or length of stay in secondary care. The project will aim to deliver a reduction in referrals to secondary care admissions, avoidable use of A&E and length of stay. More importantly, it will improve access, patient/family experience and prevention of longer term conditions for children, young people and their families in the borough.
- Purpose
The issues to be discussed will be individual for each child and focused on current concerns affecting the child’s health and wellbeing raised by parents and professionals. The ethos is of trying to identify issues and risks early to prevent the child becoming more unwell and improve co-ordination of care through regular tracking.
The meetings will aim to discuss each child at least once a month with representatives from key professional groups present.
The meeting will formulate a plan of action for the child which will be communicated on the next working day to the family, GP and team around the child. This plan will be reviewed the next time the child is discussed and actions completed will be monitored.
- Attendance
The full core membership of the group is expected to attend and participate at each meeting. The attendance of deputies/delegated authority will be acceptable when members are on leave.
Others will be invited as appropriate and attendance and time keeping at the meetings will be closely monitored.
- Chairing
The Meetings will be chaired by The Bridge Nurse, or a deputy agreed in advance.
- Responsibilities
The Bridge nurse and co-ordinator will be responsible for organising the meetings, inviting attendees, circulating lists of children for discussion, chairing the meetings, taking minutes, circulating outcomes and liaising with parents, GPs and other services before and after the meeting.
Professional representatives will be expected to present concise, recent information about their service’s involvement and be able to agree actions for their team.
- Membership
The core team for each meeting will be:
- the Bridge Nurse,
- the Bridge Co-ordinator,
- a community paediatrician,
- a CCNT,
- a therapist
- a school rep.
Others who will be invited to appropriate meetings will include respiratory physiotherapy, school nurses, CWDT social worker, feeding SALT, dietician, Advisory teacher for children with complex needs, GOS Palliative Team and Richard House.
- Frequency of Meetings
Each meeting will start promptly and be for one to one and a half hours with 6-8 children discussed.
The group discussing Stephen Hawking children will meet weekly.
The groups discussing Beatrice Tate children will meet twice a month.
The group discussing the other children (mainly under CDT) will meet twice a month.
- Accountability and reporting
The Bridge team are accountable to Barts Health, Women and Children’s CAG and will be reporting regularly through Owen Amadasun – Project Lead (Service Development) to theCAG, The Children’s Integrated Care Steering Group and Tower Hamlets CCG.
(Drafted by Dr Laura Hayman, 16.07.15)