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Integrating care to reduce hospital admissions

Practices in Mid-Norfolk have established a local 'integrated care hub' to provide joined-up, multi-disciplinary care in patients' own homes, writes practice manager Judith Wood.

Integrated, multi-disciplinary care enables better management of patients in their own homes (Picture: Blend Images/Rex)
Integrated, multi-disciplinary care enables better management of patients in their own homes (Picture: Blend Images/Rex)

Elmham surgery, a GP practice in East Anglia, has developed an innovative, integrated care solution to improve the care of elderly patients in their own home and reduce hospital admissions.

The scheme, now adopted by all practices in the Mid-Norfolk locality, led to a 28% reduction in emergency hospital admissions and an 8% cut in admissions to care homes between 2010/2011 and 2011/2012.

The project was started more than five years ago, when Elmham was identified as a performance outlier: it had high emergency admission rates, of older people in particular, and was a high prescribing practice.

I was working at Southern Norfolk PCT at the time and, along with the trust’s director of public health, started discussing, with the practice, ways of addressing these issues.

Robust formulary

The practice introduced a robust formulary to manage prescribing and began to analyse the admissions. What emerged from analysis was that, in the case of elderly patients, it could be non-medical issues that created the tipping point: for example, a son or daughter going on holiday leading to a GP having to refer the patient to hospital for a minor illness because they couldn’t be properly looked after at home.

At the time, referring a patient to a social worker involved going through a call centre which was quite a protracted process. Elmham was keen to find a way to bypass this, so clinicians could have direct access to community resources with the primary aim of preventing elderly patients having to go into hospital in the first place, as well as speeding up their discharge if they were admitted.

After speaking to the director of social services, it was agreed that a six-month trial be set up to test a totally new way of working. By this time I had become practice manager at Elmham surgery.

The pilot involved the GPs and nurses at Elmham having access to a named social worker; named community nurse; and named dementia nurse plus direct access to the community therapy team. The aim was to harness the existing multi-disciplinary approach for palliative care patients and focusing on person-centred care.

The first six months was challenging and largely constituted trying to establish how to communicate with one another, other since social services and health teams have a different language and priorities.

There the odd instance of brinkmanship but even the initial trial made a difference to the care we were delivering so the trial was extended further.

In 2009, the Elmham scheme became a formal part of the DH’s national Integrated Care Pilots and was fully evaluated by a research team. The scheme was also rolled out to the five other practices in the Mid-Norfolk area.

Integrated care hub

While we do not have an integrated budget with the other agencies this was about sharing the resources. We established an ‘integrated care hub’ at our local hospital in Dereham. This comprised a new post of a community matron (who, unusually, works with patients in care homes); a new post of a community geriatrician; social workers; district nurses; a dementia support nurse; and community therapists.

At Elmham, we hold weekly multi-disciplinary meetings involving the GPs, practice nurses, district nurses, social workers, the dementia support nurse and the practice manager.

Vulnerable patients are identified and discussed and management plans formulated. When patients are admitted to hospital, the meeting provides a forum to reflect on the admission, consider whether it was avoidable and steps that could be taken to prevent delays when the patient is ready for discharge.

This different approach means we can ensure resources are available to manage patients at home, particularly now we have a community geriatrician.

The scheme has led to an 8.5% reduction in the number of overall hospital admissions between 2010/2011 and 2011/2012 in the Mid-Norfolk area. We are leading the way in comparison to the wider NHS Norfolk area, which reported only a four per cent cut in admissions in the same period.

The 28% reduction in emergency admissions is also much higher than the national average reduction which is 16%, and the Norfolk average (also 16%).

As well as improving patient care and outcomes, this way of working also fosters improved team communication, relationships and levels of trust.

The principles underlying the integrated care solution can be easily replicated by other practices to improve clinical care to the local population.

Tips for integrating care

  • Don’t wait for structural change; take the initiative to change things yourselves.
  • When working with the different professions do not let egos get in the way. Remember to hold the best interest of your patients at heart.
  • Never say no. There will always be someone ready to find a solution or help you.
  • Data protection can appear to be a real obstacle. You can find solutions to deliver effective patient care but safeguarding patients must be a priority.
  • You do not need large quantities of money; the resources are in the system, working in a different way may be what is called for.


  • Judith Wood is practice manager at Elmham Surgery.
  • This initiative was shortlisted in the 2013 GP Enterprise Awards.

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