Transforming community care with a multi-professional team

Overview

Weymouth and Portland Primary Care Network launched a Frailty Team in 2015 as a proactive service, working across a primary care network with a 76,000 patient population. The team has gradually expanded over the last five years to include a wider range of clinical and non-clinical staff and formed strong links in the community through their journey towards becoming an integrated neighbourhood. With hospital admissions on the rise, they expanded their team and new ways of working, fostering the shift from rehabilitation to prevention.  

By developing a multi-skilled integrated neighbourhood team they are facilitating the hospital to community shift for older patients and helping build a neighbourhood health service that delivers more care at home or closer to home. This is a key driver for the work and builds on the aspirations within NHS England’s Neighbourhood Health guidelines. 

This initiative showcases the benefits and importance of early interventions in the community, as outlined in NHS England’s guidance on proactive care.   

What the organisation faced

Reviews of frailty service provision for older patients in Weymouth and Portland found that interventions were delivered too late in patients’ frailty journeys when they were already housebound or living in care homes. Ad hoc visits to patient homes and care homes were insufficient in effectively preventing health deterioration. Working within an ageing community, with almost fifty per cent of the population having a chronic health condition, a transformation in service delivery was essential. The organisation needed to enable direct access of patients to the frailty team, and to take pressure off GP and hospital settings. Moreover, consistency in how patients were risk assessed, educated and managed by a team with a clear scope of practice was required. 

It was essential to expand the workforce to create a multi-professional team that would be able to deliver high quality care to meet the specific needs of the older person through key components of Integrated Neighbourhood delivery that are patient focused, reduce duplication and focus on prevention.

What the organisation did

• The service expanded their team to include six advanced practitioners (APs), specialist frailty nurses, paramedics, occupational therapists physiotherapists, care coordinator and health care assistants. This made it easier for patients to be seen by the right professional at the right time.
• A joint triage multidisciplinary team was introduced to review referrals together and coordinate a single, consolidated response where possible. Over a six-month trial reviewing 151 patients, 45 per cent had been referred to multiple services. In this group, duplicated assessments were reduced in 87 per cent of cases. This led to significant time savings for staff and reduced the burden on individuals, avoiding unnecessary assessments ranging from short follow ups to lengthy frailty assessments.
• Ageing Well Clinics were set up in community settings to discuss health holistically and enhance knowledge of older patients and their carers. Topics such as blood pressure, bowel health, and nutrition are discussed and it is used as an opportunity to link with social prescribers and care coordinators, ensuring the right level of intervention. 
• They developed a strong focus on risk profiling, comprehensive geriatric assessments and the creation of personalised care and support plans through upskilling staff under the additional roles reimbursement scheme (ARRS) which provides funding for Primary Care Networks to recruit specific roles to boost care capacity. 
• They improved diagnostic rates for dementia for those living in care homes using DiaDeM; a tool used to support GPs with diagnosing dementia. They used this 47 times over an 18-month period. This negated the need to refer to memory assessment services in secondary care, avoiding the stress of hospital settings for older patients.
• Strong links and regular visits were arranged with care homes, and APs worked with care home staff on improving services. This included the creation of sick day guidance. 
• A pilot for Falls Management Exercise classes (FaME) has been launched and is run by a physiotherapist advanced practitioner. This intervention has been shown to reduce the risk of falls and fractures by up to 54 per cent.  
• A joint triage multidisciplinary team was introduced to review referrals together and coordinate a single, consolidated response where possible. Over a six-month trial reviewing 151 patients, 45 per cent had been referred to multiple services. In this group, duplicated assessments were reduced in 87 per cent of cases. This led to significant time savings for staff and reduced the burden on individuals, avoiding unnecessary assessments ranging from short follow ups to lengthy frailty assessments.

Takeaway tips

• Understand the key needs and challenges of your local patient cohorts.  

• Develop strong links with other community services to thrive in neighbourhood teams.  

• Consider how to transform services through the use of multidisciplinary teams.  

• Invest in staff development and training where possible to enhance care.