Mission possible: finding emergency respite nursing care in the community on a Friday

A GP called for help just after 2pm on a Friday afternoon: A patient on an end of life pathway needed emergency respite care outside of hospital asap. The GP called the PICS Care Navigation Service which had been set up in partnership with Nottingham West Primary Care Network to enhance lives, reduce hospital admissions and take pressure off GP services.

The logistics of finding and funding nursing care can slow down urgently needed support and prevent families from being able to fulfil the wishes of their loved one. This timeline details what happened between that call and the patient being matched to expert nursing care in a home, not a hospital. But it doesn’t stop there. The Care Navigator keeps going until funding for the place is secured for the family.

Timeline from a referral for Care Navigation to discharge   (timings approximate)

Dr Rhodes, Chilwell Meadows and Valley Surgery explains the impact of this work: “The Care-Coordination Service has prevented admissions to hospital by rapidly sorting out care for patients and their dependents. It makes a real difference to the lives of patients and saves significant time of doctors.”

A step further: transforming acute and urgent responses into personalised and holistic care

Lynnette Chadwick is the ICP’s PCN Care Coordinator, working in a similar role with the Enhanced Health in Care Home Service. She integrates care for a patient by pulling together services at a local level and forming pathways between them. PICS and the GPs co-designed the role so that patients are put first and their whole being is the focus.

Lynette is very well connected, working closely with the wider PCN team, as well as GPs, Practice Nurses, District Nurses, Social Workers, Pharmacists, Physiotherapists, Social Prescribers, Care Homes, Dietitians, NHS funding bodies and more. She explains:

“I work hand-in-hand with colleagues across Notts who support patients. Once assessed by a clinician, I act swiftly to find patients appropriate support from a variety of teams and services. This is important to reduce the risk of their conditions getting worse or destabilising. Our fast-acting service helps patients feel better before their condition becomes serious – like in this instance:

Case study

A care home colleague contacted our Enhanced Health in Care Homes Service team because one of their patients is losing weight and is generally deteriorating. They’re not ill enough to call in acute services, but they’re uncomfortable and it’s likely they will get ill without preventative care. Our administrative team has access to Pharmacists, Occupational Therapists and Dieticians, so we arrange for the patient to be assessed and we support onward referrals and medicine requests. This direct route to specialist care avoids the need for a visit from the GP. The patient starts to feel more comfortable really quickly. They don’t become poorly and frightened, and they don’t go into hospital. We ensure their patient records are kept up-to-date so that the GP and their other clinicians are involved.

Dr Charles, GP at The Manor Surgery, Beeston shares their perspective of this service: “It’s quite difficult for a GP in the acute situation (often on a home visit with a patient) to know what appropriate resources are available and this service is invaluable in this respect.”

Earlier this year, the PICS non-clinical Care Navigation Service was commissioned for another four years across Nottingham West and Mid Notts. Nicky Render, PICS Care Navigation Manager explains the strategic benefit: “I believe our Care Navigators are crucial in ensuring patients receive the right care at the right time by the appropriate services within the community. Care Navigation has proven to be a core building block of Population Health Management across integrated care partnerships. They coordinate resources around a person’s needs and help prevent admission to hospital or readmission.”

Dr Muthoot, GP at the Linden Medical Group agrees: “Their interventions have been vital in breaking a chain that would have inevitably led to the admission of patients and often with recurring admissions after that. Their follow-up support also helps identify patients who later need different support and treatment and results in early, timely and appropriate admissions, when needed.”

From care homes to Dementia Cafés – how PCN Dietitians are preventing ill-health

Did you know that as you get older or frail, it can actually be healthier to eat high calorie foods like pies, cakes and chips?

Since the autumn of 2020, Emily Fowkes has been a Dietitian for Nottingham West. A member of the PICS Enhanced Health in Care Homes team, she works within a specialist team commissioned by the Primary Care Network and co-designed with PICS. She explains:

“What constitutes healthy eating and drinking changes for us as we get older, especially if we’re frail, ill, have problems with swallowing or are living with neurological diseases like dementia. We can forget to eat and drink, our sense of taste changes, our medicines might complicate our digestion or put us off our food, or we might not be able to chew and swallow like we used to.

“It’s not well known that once an older person or someone with chronic or complex conditions starts to lose weight, it is very difficult for them to put it back on. They risk becoming malnourished, which can exacerbate frailty and ill health. However, if their bodies get the nutrition they need, the benefits are:

• better skin hydration and integrity, which is more comfortable for the patient and help to reduce the risk of   pressure sores;
• stronger immune systems, which helps us all stay well and manage other conditions more successfully;
• stronger muscle mass, which enables greater mobility and independence; and
• improved mood, better wellbeing and feeling in more control.

“My job is to intervene early, before weight and ill-health caused by poor diet becomes a problem for someone. My care prevents decline of health, promotes wellbeing and brings comfort to residents and patients. Because I don’t have minimum referral criteria, I have the scope and freedom to work proactively with patients, GPs, nurses, carers and professional care staff. I’ve seen in my previous work how much care homes need this sort of specialist support, so I feel very happy to be able to help them with that.

“I join clinicians with their weekly care home rounds and I conduct assessments and reviews of residents. I have produced a Nutrition and Hydration Care Home Pack which has been sent to all Nottingham West care homes and includes advice, recipes and guidance, supporting them to manage malnutrition successfully.

“I’ve reached out to local speech and learning therapists and community dietitians to explain how I work and share the guidance I’m producing for them to sign off. Speech and language therapists will work with people who have difficulty swallowing; they advise on which consistency of diet and fluids is safe for a resident. I can then offer further support within these recommendations.”

Emily recently adapted training designed for other healthcare professionals and delivered this to people living with dementia and their carers via Zoom. An appropriate diet helps keep people stronger and independent which enables them to live at home for longer and reduces their health needs with their GP or local hospital. She says: “Many carers haven’t cared for someone before; they’re looking after their loved ones with little or no experience or professional training. There is a lot to take in for them and very often, diet and nutrition continues as it always has and reflects what the rest of the household consumes.

“I think it’s really important to help these families and carers with practical advice and some specialist insight so that they can make changes to their diet. They can help prevent weight loss, malnutrition and associated health consequences such as a weakened immune system, increased risk of falls and skin breakdown, decreased mobility and low mood. The Dementia Café’ session was really well received with attendees reporting that they learnt new information and felt more confident supporting their relative now.”

Dr Paul Scullard, GP and a Clinical Director for Nottingham West Primary Care Network, said: “I had attended an amazing tutorial Emily did for our care home clinicians, where she explained the effect of poor nutrition in dementia and the elderly, and shared some simple strategies that can be put in place to support them. We were all surprised to learn that your taste preferences can change when you have dementia. On the back of this we have made new links with local support groups and she is now doing educational sessions for patients and their carers in the community. This has been a great piece of work and we are looking at rolling out more widely in the future.”

Working together to make lives better

Maria Ballantyne, Group Manager, Living Well South talks about the a strength based approach can empower people to live their best lives…

As we all know, the past year has seen us change the way in which we live to such an extent that we are all feeling a little nervous of the ‘what next?’. It is good to acknowledge that we have been through a difficult time, but we probably have been able to do more than we thought we could? Maybe? Yes? No?

There comes a time in some people’s lives when we feel that we need support and it may be that we ask family, friends and neighbours before we would think about contacting Adult Social Care Services. I wonder, why we do contact our friends and family first, is it because they offer to support in a small way? Support in a big way? Reassure us that everything will be okay and will support us until we feel better? Its certainly food for thought.

In the new world we live in it is important that we really think about how we, as providers of health and care services, can continue to offer support in such a way that doesn’t overwhelm and undermine your confidence but, how can we do that?

In Adult Social Care Services we are working to adopt a Strengths based approach. What that means is we are going to do is to talk to you about what you can do, rather than what you can’t. We are going to ask you what support you need turn it around? We know that everyone has strengths and we will concentrate on those to make sure that your confidence and self-worth are the focus for what is important to you. We are going to have a conversation with you so that you can tell us what it is that you want to achieve, and we will offer you the support to achieve this.

There are a number of ways in which this can be done – it may be via a Carers hub, a service in the Community such as a knitting service or, it may be a Promoting Independence Worker who can look at community visits to build your confidence going to the corner shop.

Whatever it is that you need to maintain or improve your independence our strength-based approach will allow us to do this, we are working with our colleagues to maintain your independence rather than create a dependence. Perhaps most importantly of all, we want to make sure that you can ‘live your best life’ whatever that may be! Everyone is different, everyone is unique.