Oxford Terrace and Rawling Road Medical Group (OTMG-RR) is a GP practice, situated in Central Gateshead. The population of about 15,200 patients is predominantly deprived, with high numbers of refugees and asylum seekers.We have a particular passion for patients with complex care needs and using a risk stratification tool we identified that about 2500 of our patients with multiple comorbidities were at high risk of being admitted to hospital. 100 of these patients were house bound and did not meet the criteria for access to community matrons. Despite having community matrons attached to the practice our trajectory for attendances and admissions to hospital were increasing.
An experienced Older Persons Specialist Nurse (OPSN) was appointed to implement the principles of Comprehensive Geriatric Assessment to achieve continuity of care for elderly patients with complex health and social care needs. Initial patients were identified through a triangulated approach: those that need a flu vaccine, were attending A&E regularly and high requesters of home visits. Referrals were received from the team thereafter.
In the first 8 months of this project to May 31st 2014 , 94 housebound patients with an Average Age of 85 years ,were referred to the OPSN and had care planned and implemented, using the principals of Comprehensive Geriatric Assessment. This role was based directly within the practice and provided the benefits of co-production with the core members of the PHCT, patients and their carers working as equals in collaboration to optimise the health and well- being of frail older people.
Equally, there were rewards to the practice in terms of opportunities for peer support; networking and sharing, and multi-disciplinary working. The appointment of a Nurse Specialist as a clinical leader with knowledge and skills in the care of older people, wide experience of effective multi-disciplinary and interagency working and awareness of the local and national drivers affecting the care of older people was a key component in the success of this.
In 8 months, attendance and admission though A&E was reduced by 54%. Requests for home visits were reduced by 81%. In addition: • All patient’s on the case load had a comprehensive care plan that was uploaded onto the adastra system for external organisations to enable integrated working; • 53 carers were identified and also received support and were signposted to appropriate services.
This post is now substantive in the practice working as part of a practice based complex care team. Review of the case mix identified that there was a need for a step down process and also access to primary care based occupational therapy (OT). Two Health Care Assistant posts were redesigned to develop a Primary Care Navigator role and funding was identified to appoint an OT in the practice. They are now part of a practice funded complex care team who work in an integrated way, using the practice IT system to manage frailty and complex care in the community.