Community hubs: Good news for patients and care staff

15th February 2018

Improved patient experience, reduced GP call outs and lower hospital attendances are among the benefits arising from the community hub prototypes, according to case study feedback.

Health and social care professionals working in the hubs have attributed these successes and others to the fact that new approaches have come directly from frontline staff. Employees also felt that a sense of urgency had arisen from the 90-day timescales agreed for most of the improvement projects.

shaking hands

Now, Caring Together partners are developing plans for the staffing structures that will be needed to turn prototypes into sustainable services while junior support roles will be created to release more skilled employees for proactive care management and rapid response.

Meanwhile, arrangements are being made to introduce community hubs in Eastern Cheshire’s other three localities (Chelford, Handforth, Alderley Edge and Wilmslow; Congleton and Holmes Chapel; and Macclesfield) and to collate hard data underpinning the benefits described in case studies.

Benefits – Team Bollington, Disley and Poynton (BDP)

Whole system approach to older people’s services

What was done?

  • Fifteen frail patients were identified when they received a Lifeline personal alarm.
  • Proactive assessment was carried out by a nurse or social worker using a standardised tool for measuring fraility.
  • The frailty level was identified and care plans developed where appropriate.
  • A pathway and care regime was agreed for each patient in line with their frailty level.

What are the predicted outcomes?

  • Improved confidence for the patients.
  • Reduction in the number of falls.
  • Reduction in the number of A&E attendances arising from falls, wounds and frailty.
  • Increased use of self-management tools and third sector services.
  • Improved health and wellbeing of older people.

Unified management of diabetes

What was done?

  • Primary, community and acute care were brought together to draft a diabetes care model.
  • The patient recall process was standardised and agreed clinical codes implemented.
  • Improved liaison between services has resulted in the diabetes consultant visiting GP practices regularly to offer advice and support.

What is the benefit for the patients?

  • Patients empowered to be involved in their own care.
  • A robust service with access to a multi-disciplinary team.
  • Reduced reliance on secondary care.

Medicines management

What is being done?

  • Training of repeat prescribing staff at McIlvride Medical Centre and Priorslegh Medical Centre, Poynton and The Schoolhouse Surgery, Disley.
  • Technicians then training staff in other practices.
  • Training on the processes used to recall patients needing chronic disease management. This has crossover relevance for Team BDP’s medicines management and diabetes projects.
  • Interviews have taken place to recruit a clinical pharmacist to work in the GP practices.

What are the predicted outcomes?

  • Increased safety and quality of repeat prescribing.
  • Improved prescribing efficiency.
  • Improved access to medication advice and support for patients.
  • Equitable access to quality medication reviews for all patients.
  • Freeing up of around one hour a day for every GP.

Carers’ assessment

What is being done?

  • Collaborative working between Cheshire East Council, the BDP GP practices and Peaks & Plains Housing Trust to create a baseline carers’ list.
  • District nurses and GPs signposting carers to social workers for assessment.
  • A new referral form is being piloted by all healthcare professionals.
  • Local businesses have been approached to provide discounted services to carers.

What are the predicted outcomes?

  • Improved physical, mental and emotional health and wellbeing for carers.
  • Improved confidence for carers.
  • Increased carer uptake of the Alert Card for Emergencies (ACE).
  • Carers empowered to take responsibility for their wellbeing.

Benefits – Team Knutsford

Dementia pathway

What was done?

  • A consultant psychiatrist started leading clinics in GP practices.
  • A primary care review pathway was developed for stable patients.
  • Patients were transferred from consultant care to primary care where appropriate.

What is the benefit for patients?

  • More rapid diagnosis.
  • Reduced number of appointments as reviews are combined with reviews of other long-term conditions in the GP practice where possible.
  • Improved access to consultant for patients with complex or advanced dementia.
  • Reviews taking place in GP practices rather than hospital, allowing patients to remain closer to home.

Compassionate community model for end-of-life and palliative care

What is being done?

  • Development of a standardised, whole-system approach to end-of-life care.
  • Palliative and end-of-life care that promotes better health.
  • Development of “communities to care”.
  • Collaboration to create and deliver outcomes-based, standardised improvements in palliative and end-of-life care.
  • Development of a cohesive workforce that understands end-of-life care and each other’s roles.

What will happen as a result?

  • Increased availability of community-led care and support.
  • A cohesive workforce that understands end-of-life care and each other’s roles.

Care services directory

What was done?

  • A survey carried out to understand if clinicians refer to the third sector and have access to the necessary contact details.
  • Liaison with compilers of the Live Well Directory to ensure appropriate health services are included and to enable third sector services to be identified more readily.
  • A format agreed for a local A4 care service directory.

What will happen as a result?

  • Patients empowered to be involved in their own care.
  • Care tailored to the individual.
  • Improved knowledge of local third sector support.

Knutsford nurses

What was done?

  • Workshop held for practice and district nurses to identify priorities and opportunities to work differently.
  • Joint home visits and holistic assessments carried out by community matrons and practice nurses.
  • Regular “Keep in Touch” meetings established.
  • Training sessions made available to both practice and district nurses.

What happened as a result?

  • Improved confidence and ability to manage health and wellbeing.
  • Longer but fewer appointments.
  • Improved management of long-term conditions.
  • Reduction in avoidable A&E attendances.

Care home support

What was done?

  • A community paramedic from North West Ambulance Service visited Leycester House Care Home at least twice a week to provide clinical support and advice to staff.
  • Training on falls prevention/management and sepsis was provided to staff.

What happened as a result?

  • Staff received training on falls prevention/management and sepsis.
  • Staff were supported to deal more confidently with medical issues.
  • Residents had improved access to medical help.
  • Residents had improved support from care staff in reducing falls.
  • GP visits shorter in length because initial clinical assessments were being carried out by the community paramedic.
  • Visits by multiple GP practices were reduced because the paramedic was able to see patients from across practices.

Atrial fibrillation

What is being done?

What are the benefits for the patient?

  • Early detection of atrial fibrillation.
  • Effective anticoagulation to prevent clots forming in the heart.
  • Improved health and wellbeing.
  • Reduced risk of a stroke.

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