Posted by Daniel Harper at 13/07/2018 15:33:21
Dr Becky Prince, GP partner at Snodland Medical Practice explains how health and social care professionals are coming together to support people with complex health conditions in west Kent.
How has caring for people with complex health needs changed?
As people live longer, we are seeing more and more people with multiple health conditions. For example, a frail older person who has diabetes, heart failure, respiratory problems and dementia will be seen by a number of healthcare professionals with skills to treat each of their separate conditions. To make sure this one person’s care is joined up, professionals with different specialist knowledge are now working together as a team to develop and bespoke care for them.
Who is in the team?
We are bringing together all relevant professionals for each of the seven geographical, ‘GP cluster’, areas in west Kent and each team may differ slightly depending on the professionals working in the area and the skills that are needed.
For our geographical area, the Malling GP cluster, the team comprises complex care nurses, who specialise in treating long-term health conditions; community nurses, who carry out health checks, tests and treatments; a mental health specialist; a dementia practitioner; health and social care co-ordinators, who organise the team to make sure everything gets done; and social care representatives from the local authority. We are also inviting a geriatrician, who specialises in treating older people, and the hospice team to get involved. Each patient’s GP will dial-in to participate in the meeting and discuss their specific care needs and any concerns with the team.
How does it work?
The team meets once a month. A GP or member of the team will ask patients who are struggling to manage their health or are at risk of deteriorating and going into hospital, whether they would be happy for the team to discuss how we can best support them. Everyone in the team considers the patient’s needs and together we draw up an action plan, nominating one person in the team to be the patient’s point of contact.
Sitting down together to work out what is best is definitely a step forward. Getting the whole team’s view is a lot better and a lot more focused than when I used to assess someone and then send off a string of referrals, which take time to be processed. Now, we may decide in the meeting that the dementia nurse and GP could visit the patient at home together and diagnose dementia without having to visit a consultant. Or if we are concerned about the patient’s safety at home, for example we believe they are at risk of falling, the team may agree that the patient needs to be assessed at home by a health and social care co-ordinator or have a home hazard assessment from Kent Fire and Rescue. These can be organised quickly so that patients are visited in a matter of days or within a couple of weeks.
How does it help?
For me, it feels like I am making a real difference. We are really focusing on the improvements that patients need to make their lives better and easier, and my patients are better supported with the right people looking after their needs.
Sometimes we provide practical support such as organising for special equipment including hand rails or hoists to be delivered. We even moved one person’s bed downstairs as they were struggling to get to the kitchen to prepare food and drinks. Other times we discuss more medical needs, such as whether a patient requires particular tests or may need counselling.
How do the services work together?
I can focus on patient’s physical and psychological wellbeing but as a team we look at the bigger picture and other professionals can help with such as advice on housing benefits, organising carers to visit and organising attendance at social groups.
A hospital is not necessarily the best place for frail people with complex, long-term conditions to be cared for. This is definitely a more sensible way of working together, reducing the pressure on hospitals and, most importantly, helping the patient to be cared for in the comfort and familiarity of their own home.
Find out more about a patient’s view on the local care plan.