Working Together to put Patients First

8th December 2014

Health chiefs have launched a pioneering ‘Working Together’ service that helps people return home safely and happily after a spell in hospital.

The Working Together partnership in Eastern Cheshire sees various health organisations co-operating to ensure that patients get the ongoing care they need to live independently at home following discharge.

The scheme is managed day to day by care co-ordinators Hollie Home and Louise Rycroft who contact health partners to put in place a wide range of support which might include home visits by:

  • District nurses to change wound dressings
  • Occupational therapists to install equipment such as grab rails and stair lifts
  • Physiotherapists to help patients walk again after surgery.

Started in July, Working Together has already helped more than 200 patients and, although it is early days, evidence is building that the service is reducing hospital readmissions – which is good news for patients and the taxpayer alike.

The scheme is funded by NHS Eastern Cheshire Clinical Commissioning Group(CCG) in partnership with Bollington Medical CentreMcIlvride Medical Practice and Priorsleigh Medical Centre, Poynton; and School House Surgery, Disley.

The CCG will review the innovation after 12 months and will then look to extend it across the area’s remaining 19 GP practices if it has achieved its aims.

Based at Priorslegh Medical Centre, Hollie and Louise receive hospital discharge notes forwarded to them by GPs from all four practices. They also have permissions to browse hospital discharge lists to make sure no patients have slipped through the net.

They then contact the patient and their family to ensure that ongoing health needs are understood and can be met.

Of the 300-plus patients or carers who have contacted the service so far, more than 200 have needed practical help at home as well as general advice.

Jacki Wilkes, the CCG’s associate director of commissioning, said: “Working Together is a ground breaking service for 33,000 patients across four GP practices.  It provides a single point of access for patients in Bollington, Disley and Poynton who may need extra help to settle back in at home after hospital discharge.

“As well as sourcing care, the service educates patients and their carers to give them the confidence to manage their own healthcare. I cannot think of a better example of the Caring Together ethos being applied in practice.”

Working Together calls on the expertise of partners including Macmillan Cancer Support and district nurses, community physiotherapists and occupational therapists, care agencies, voluntary organisations and local authority social care teams.

The following comments are typical of the overwhelmingly positive feedback from patients so far:

“Everything has been sorted. Thank you so much for your help. What a fantastic service!”

“This is so helpful. It will be great for me and my husband.”

“You are a God send and I’m more than impressed with the service.”

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