Extended Primary Care Team

1. Extended Primary Care Team Complex Care in our Neighbourhood

2. The Extended Primary Care Team: Who are we? A social prescribing service with Health Connectors and Care Planners working along side one another to serve a population Building on the success of the Mendip model in Frome, Somerset Enabling people to self manage, build confidence and develop personal resilience

3. Approach • Unique approach in identifying what ‘matters to me’ • Having the time to explore issues in the persons own home • Use of ‘MECC Making Every Contact Count) Healthy Conversation Skills’ and PAM – Patient Activation Measure • Assessment tool enables patient led care and support to set goals • Web based directory and real time feedback https://healthconnectionsfandg.org/directory/

4. Enablers • Integrated Care & Support across all services within the locality • Ongoing engagement with stakeholders • Established information agreement that is GDPR compliant • Robust Training and Induction programme for staff and ongoing supervision • Established evaluation process on a 3 monthly cycle • IPA – Risk Stratification Tool – to Identify appropriate people • Key outcomes recorded to EMIS which achieves real time feedbackMDT – Health Connectors attend Multi-Disciplinary meetings

5. Addressing wider determinants of health to improve outcomes

6. Cohort 4 - 32 Patients – Primary Care Contacts (GP, Nurse, Clinics, Annual Reviews) Complex Care Team involvement commenced 07.09.2018

7. Cohort 3 - 38 Patients Non – Elective Hospital Admissions Complex Care Team involvement commenced 08.08.2018

8. Patient Story – Mr & Mrs B Background: Referred by GP after they attended a routine appointment for Mr B. GP requested assessment of balance and mobility, and noted concerns about carer stress. Mr B has prostate cancer, Type 2 diabetes and arthritis in hips and lower back. He had been experiencing continence problems and had several falls at home, and was not managing diabetes properly. At the time of referral, Mr B had recently attended A&E and was treated for UTI and fever. They had also made frequent calls to 111 and GP practice prior to their presentation to ED. Initial Assessment: On initial meeting, exploratory discussion used to understand presenting situation, impact on their wellbeing and managing daily activities - and how they wanted their situation to improve. Both Mr & Mrs B reported feeling ‘desperate’ due to Mr B’s deteriorating health and changing care needs. They did not feel that they fully understood what was happening with Mr B’s healthcare or that he was getting appropriate support. Mr & Mrs B did not know what help was needed or how to access this to improve their situation. Mr B had not been out of their home for 8 weeks and Mrs B did not want to leave Mr B at home due to risk of falls and continence issues. On initial assessment, EPCT also picked up concerns about Mr B’s short term memory.

9. Patient Story – Mr & Mrs B Identified Goals for Mr B: • Improve balance and mobility and address safer mobilising around the home • Manage incontinence • Improve mood and sleep, and reduce stress • To go outside and to be able to see his grandchildren Identified Goals for Mrs B: • Improve sleep and reduce stress • Be enabled to prioritise managing her own health condition

10. Patient Story – Mr & Mrs B Health Connector and Care Planner working collaboratively to support and enable change to achieve personal goals of both Mr & Mrs B through linking them to the right services within the health, social care and voluntary sectors. Activity has included: • Referral to continence service • Referral to diabetes team • Arranged home blood tests for essential medical review for both • Assessment by RMN to assess mood, memory and cognitive impairment • Provided equipment – bed lever, high backed chair, pressure cushion, walking aids, commode. Requested adaptations to property including grab rails and concrete step to enable safer transfer in/out of the house including liaison with local Council housing team. • Support to arrange patient transport for medical appointments • Engaged with tailored Home Exercise Programme to improve balance and mobility • Support to maximise income - applied for Attendance Allowance and review eligibility for Carers Allowance • Referral to Adults’ Health & Care for Carers Assessment and Take a Break service, and to Princess Royal Trust for Carers to develop Emergency Care Plan • Referral to Royal British Legion for pendant alarm • Provided information for local clubs and groups to meet interests and needs of both • Registered with Telephone Preference Service to stop unsolicited marketing calls

11. Patient Story – Mr & Mrs B Outcomes • Ongoing GP liaison to manage health care needs - enabling greater understanding of the issues impacting on health & self-management • Safer mobility and transfers, and balance improved • Income increased to fund telecare and pay for taxis • Carer stress reduced as now receiving a break and pendant alarm provides reassurance to enable Mrs B to leave Mr B for short periods • Mrs B has been able to attend review to better manage own health condition • Mr B to attend Men’s Social Group and Mrs B to join Brendoncare Club locally • After not seeing their daughter and grandchildren for four months, Mr & Mrs B have recently spent a day out with them EPCT has enabled joined-up care to meet holistic needs of both Mr & Mrs B with input from GP and community health teams, Adults’ Health & Care, and voluntary sector. Referrals to multiple agencies have happened in a timely manner, avoiding escalation to point of crisis, and avoiding potential for further hospital admissions and presentations to primary care.