Community Focussed One Stop Shop. A multi-disciplinary team supporting patient centred health and wellbeing and reducing demand on unplanned care

Background: Of the 75,000 patients aged over 20 years registered with a GP in Crewe, around 20,000 live in the highest 20% of national socio-economic deprivation.

Unmet need is demonstrated by patients presenting in crisis, unplanned admissions and emergency care, prolonged admissions, delayed hospital discharge, late diagnosis of significant health conditions, patients with reduced life expectancy

Our aim was to understand the problems and barriers in accessing support, enable engagement with the services, and reduce demand on emergency and unscheduled care.

 

Approach: We applied and were awarded funding of £120,000 from the Better Care Fund, the requirement that our project aligned to the frailty agenda and was tailored to the local population health needs.

 

We involved:

Transformation and Population Health Project Manager - to identify cohort of patients to invite, and to establish Information Governance rules.

Care Community Operational and Support Managers - to project manage and lead on staff team recruitment which includes: Care Coordinator, Physiotherapist and assistant, dietician, social prescriber and GP, each leading 4 stations at the clinic.

District Nurse Team - experienced in establishing a Leg Club model successfully increasing recovery and wellbeing.

Care Community Clinical Lead - establishing clinic operation and liaison with secondary care Frailty Team.

PCN Manager - good communication and Data Sharing Agreements with all 5 GP practices.

Community and Voluntary Services - to establish their involvement.

Patients - experience of those attending the Leg Club.

We used CIPHA (Combined Intelligence for Population Health Action) to identify patient cohort, looking at Patient Need Group and Resource Utilisation Data, selecting patients mainly from Patient Need Group 5 and those in the highest resource utilisation band.

The clinic is a 3 hour session, with patients personally invited and welcomed, spending time at each of the 4 stations and time with other services present.

 

Results: Over 50% of those patients identified and contacted attended. Feedback obtained from all attending showed recurring themes. Patients valued time in a non-medical setting to discuss the issues important to them such as poor mobility, loss of confidence, poverty, loneliness and low mood or motivation.

With each professional using the patient centred care model, they were enabled to engage with support appropriate to them.

The 12 month resource utilisation data showed overall reduction in unplanned emergency care service utilisation for all cohorts of patients who had attended the intervention.

Implications:

With feedback we changed the clinics location, retaining a community non-medical setting, improving access and privacy requirements.

Workforce support to align with the clinic ethos and aims for positive patient and carer experience was crucial.

How it was presented to patients was important. We understood the term Frailty, but it was a barrier for patients. We changed the F in CFOSS to “Focussed”.

We plan to extrapolate the model in line with the NHS 10 year plan, local service transformation and our specific population health needs.

By identifying other cohorts of patients with, for example respiratory illness, mental health, orthopaedic or vascular disease should be successful in changing patient outcomes.