Incorporating the NHS Long term plan, and in response to the Covid-19 crisis and its impact on care homes, a new team has been assembled in Nottingham West Primary Care Network to support care home staff, residents, families, primary care and community services. Laurie Chadburn, Clinical Care Home Lead in the Enhanced Health in Care Homes Service explains how the new team works…
Since coming into post in September as Clinical Care Home Lead for the Enhanced Health in Care Homes Service (EHCH) at PICS, I have had the pleasure of introducing myself and the new service to the nursing and residential homes across the Nottingham West PCN patch.
It was really important to have these face-to-face and video call discussions to discuss how we can work together and how we will be supporting the care staff, residents, families and community services to provide a specialist clinical response. This service is specifically designed to improve the access to the health services received by residents in care homes and integrate and streamline community referral pathways.
The EHCH team, which will be complete mid-November, is made up of a Registered Adult Nurse, a Registered Mental Health Nurse, a Physiotherapist, three Occupational Therapists, a Dietician, three care home administrators our teams will also have a close working relationships with the six PCN Pharmacists already in post.
We will also continue to work closely with Jess Waterhouse and Wendy Berridge who have done incredible work with their Respect project across all NW care homes.
So what will be doing? Well, our remit will include weekly ‘home rounds’ available to every care home on the patch to reduce the care home workload for GPs and Advanced Nursing Practitioners to improve the access to health services for residents.
We will also be making direct referrals to other teams, for example Community Nursing, Therapy, Dementia Outreach, Community Matrons etc.
The integration of community services working closely with PICS’ specialities will be pivotal in ensuring the residents in care homes receive an equitable service across the patch – this can only be achieved by a multi-disciplinary team approach.
So how does EHCH work?
All residents newly discharged from hospital or admitted to the care home from their own homes will have a Clinician from the EHCH team complete a full holistic assessment within seven working days.
This will identify any requirements for specialist community services and will support the GPs in providing medical care, when required. We will develop a care plan for the resident and our goal is that all residents will have a holistic assessment completed which will also be shared with community teams to improve referral processes and reduce duplication of workload, thus improving the patient journey.
Mark Griffin, a Registered Mental Health Nurse, and I will be working closely together as the Clinical Leads already in post and are offering training and educational support to ensure the staff feel competent and confident to help reduce hospital admissions and ensure their residents receive the best possible care and ‘at home’ treatment available to them.
We recently spent the morning with Queenswood care home in Beeston to provide a training session on blood pressure monitoring and completing documentation to promote early recognition of a deteriorating patient and Sepsis risk. This was very well received (see photo) and they are looking forward to further training opportunities.
We’ve had a great response from care home staff and our colleagues across community services, GPs, PICS, the CCG and across the local health and care system and this has really encouraged us to progress and lead with the implementation of this service.
We are at the forefront of change and to be driving the integration and collaboration to improve the patient experience is very exciting for us all.
