Care Home Liaison Manager - reducing hospital admissions

The West Suffolk Care Home Model is a partnership between NHS West Suffolk Clinical Commissioning Group (WSCCG), West Suffolk Hospital, St Nicholas Hospice Care, GP practices, out-of-hours, Care UK, the ambulance service and care homes.

The model delivers better support to care home residents and their families by talking with them about planning for an emergency and discussing in detail their future care wishes. The creation of individual Personalised Care and Support Plans means everyone involved in caring for an individual knows what to do in an emergency.

Over 500 care home staff in west Suffolk has received training from St Nicholas Hospice Care, giving staff the confidence they need to have the conversations about future care wishes. By having an emergency personalised care and support plan in place it means that GPs, out-of-hours and the ambulance service are clearly guided by the wishes of the patient in what care should be administered.

As a result, month on month, admissions from west Suffolk care homes into West Suffolk Hospital have reduced by following the wishes of care home residents contained within their personalised care and support plan.

Dr Ed Garratt, chief officer, NHS West Suffolk Clinical Commissioning Group said: “To be recognised nationally is a great achievement for all individuals involved with the care homes model and highlights the importance of an integrated working approach to deliver the best outcome for patients. “Working with our health and care partners in new and innovative projects is one way of addressing the many challenges facing the NHS. Our CCG will continue to seek out effective partnerships that will deliver even better local healthcare services.”

Jon Green, chief operating officer at West Suffolk Hospital, said: “This initiative is a good example of NHS working together to improve services for patients, and has also had an impact on reducing unnecessary admissions, in turn ensuring we can prioritise care for those in the greatest clinical need. “We are pleased that the project has been recognised nationally and look forward to building on its success in the future so that care home residents can continue to receive care which meets their wishes in the place of their choice.”

Pippa Wilding, head of education and outreach at St Nicholas Hospice Care said: "Most people want to be cared for or die at home or in familiar surroundings. To enable that to happen we have been working with and training care home staff to ensure they have the skills and confidence to support residents to be cared for in their usual place of residence. There are 47 homes with 1900 beds in the west Suffolk area; we are aiming to support these care homes through our training programmes and hospice outreach services.'

This project was envisaged and supported within the hardwicke House Group Practice and Susan, the Care Home Liaison Manager remains in post and doing good work within the practice, and the doctors there are now used to better maintained care planning, though the major improvements are in the care homes.

Susan has been to each home to train their staff and continues to liaise with them. We have always had weekly visits by specified GPs to each care home, but things like having 'just in case' treatments available, or at least a note in the record to prescribe, makes a huge difference.

Yes, things can be done differently and they don't have to cost a fortune, they just need people with the vision and commitment to see them through. A west Suffolk project which has successfully reduced the number of avoidable hospital admissions from care homes and improved patient care has been awarded national recognition by the NHS.

For more details contact David Cripps MIHM, Practice Manager Hardwicke House Group Practice 01787 370011

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