In February 2015 I put forward a proposal to introduce a monthly review of all residents in care homes that receive residential funding (nursing funding entitles a resident to nursing care provided by the care home) residentially funded residents have access to the community nursing intervention team in the same way that an individual in their own home would have. However it is this population group who have historically received poor input from the health care framework that should support it.
What drives this project is the need to provide proactive collaborative care rather than reactive care.
My locality has 14 care homes. I have been uplifted to a band 6 post for a 7 month secondment in order to give my service transformation idea a chance to work.
I want to review all the residents in the homes on a monthly basis to ensure we are providing the best service we can offer in terms of proactive intervention to improve quality of life and proactive palliative care (which historically has been very hit and miss in care homes) and signposting to other services if required.
This will provide the foundation for improved collaboration between the care home team, the nursing team and the GP surgery by fostering productive relationships between the residents and their care providers. It will also facilitate access to service and integration of care across organisational boundaries.
I am passionate about improving the quality of life and death for residents in care home settings. By providing proactive rather than reactive care we improve quality of care and support given to residents. Improving efficiency of service through continuity of input and better organisation of resources improves support given to care teams and facilitates good working relationships.
We are 3 months into the project and it is showing great promise. I currently have just over 100 patients on my caseload (from the 6 homes we have been in so far), I have reviewed every single one. The continuity allows myself and my band 3 Ruth to provide a much more effective service because we know our patients and the added bonus is we can respond to problems very quickly and proactively.
We are establishing good relationships with the residents and the care homes. We are providing proactive pressure care, continence care and monitoring frailty and nutritional status we are also trying to organize quick access to rehabilitation (If I can get the service commissioned I would ideally like to have allied health professionals as part of the team).
I am absolutely committed to my residents and to supporting them. I am also committed to supporting the care teams to provide the best possible quality care