A new model of healthcare delivered by GPs in Nottinghamshire for care home residents has had a dramatic impact on clinical outcomes. The initiative has lead to a reduction in emergency hospital admissions and A&E attendances, figures from the Health Foundation show.
Analysis shows that between August 2014 and July 2016 care home residents in Rushcliffe were admitted to hospital as an emergency 23%t less frequently than those in other parts of the country. They also attended A&E departments 29% less often.
The initiative was launched in April 2014 to all 22 care homes in the area (plus one just outside of Rushcliffe) and offers care home residents a package of enhanced support provided by a multidisciplinary.
Structured care package
Dr Lynn Ovenden, community services lead at Rushcliffe CCG, explains that in essence the structured care package provides improved continuity of care and more integrated support for a group of patients with complex needs. It brings together general practice and community nursing services in a more joined-up way but also includes an advocacy element.
The model was initially implemented by Rushcliffe CCG after observing that in rural areas where care home residents were registered with a single GP practice, clinical outcomes were better than where care homes had perhaps multiple practices attending, Dr Ovenden explains.
Under the enhanced support offer, care homes are assigned to a particular practice with a GP undertaking weekly or fortnightly visits to review residents. A GP reviews new residents within five days of them moving into the care home and carries out comprehensive geriatric assessments within two weeks.
At least one annual review is carried out for every patient and community follow-ups are provided within 48 hours for those newly discharged from hospital.
‘The regular weekly or fortnightly review sessions are co-ordinated with the home,’ says Dr Ovenden, who is also managing partner at the Castle Healthcare Practice.
‘The care homes we work with send us a list the day before of the residents that need to be seen. With planned regular visits it means we can offer consistent care and problems can be addressed sooner, treating something that perhaps, if left, a resident may end up in hospital with later down the line. There has also has been increased identification of dementia.’
Wider primary care team
Liaising with a medicines management pharmacist, GPs also carry out reviews of medication.
In terms of community nursing support, team members go in regularly to offer wound care, catheter management, training in areas such as continence and more.
‘Attached to that team is also a palliative care team to help with end-of-life care,’ says Dr Ovenden. ‘And there is a falls specialist to help reduce the number of falls by making sure all patients have the correct walking aids, for example. So it’s not just a GP going in regularly but a multidisciplinary team. It’s a structured system of support.’
The culture change within care homes has been significant thanks to improved relationships between care homes staff, managers and the health professionals visiting the home, says Liz Harris, senior service improvement manager - non-elective care at Rushcliffe CCG.
‘Improved communication of urgent and emergency care processes, standardised care planning and regular resident reviews means that care home staff now have more information regarding the support available to them and the processes for accessing specialist teams and urgent care.
‘Learning and specifications have been shared with neighbouring CCGs,’ she adds.
A potentially tricky issue with this new way of working, however, is that it can require some patients to register with a new practice after moving to a care home, thereby giving up a GP they may have known for a long time and built up a trusting relationship with.
‘To improve outcomes we needed to reach a tipping point of 80% of residents registered with their aligned GP practice,’ says Dr Ovenden.
This is where the value of the advocacy service comes. In this case it has been provided by Age UK Nottinghamshire, as an independent organisation.
‘The Age UK Notts Residents Representatives is obviously not attached to any health service or organisation. They explain about the enhanced service and talk through the benefits of moving to the aligned practice while also reiterating the patient’s right to choice of GP. They also provide a trusted point of contact for residents or families to raise any concerns and provide advocacy support.’
Dr Ovenden stresses that if patients do not want to change doctors they are not required to do so. Although to date, it’s an issue they have been able to manage successfully - latest statistics show 90% of residents are registered with their aligned practice.
The project began as a CCG-led initiative but later transferred to Principia MCP Vanguard as part of a whole care home programme. The vanguard site includes the GP federation, PartnersHealth, which covers all 12 of Rushcliffe’s practices. Funding for the care comes partly from the CCG and partly from vanguard site monies.
What can other practices learn from this?
This way of working to improve quality and efficiency of care may be possible when GPs come together at CCG level but what improvements can be implemented on a smaller scale?
Dr Ovenden says to ensure continuity of care and help build relationships practices could consider, where possible, making sure the same GP attends a care home and if workload allows, attends at a regular time and at regular intervals rather than only in response to a problem.
‘It’s about taking a proactive approach, so regular assessments can be carried out to address needs or problems quickly,’ she adds. ‘This allows a practice to get to know the patients better and also prevents particular residents not being seen for a long time because they had no urgent issues.
Dr Ovenden says overall the move to the new way of working has been very positive. ‘Everyone has been working well together. It has helped medical teams and community teams forge much stronger relationships with the care homes, all to the benefit of their residents.’