Community Assess and Support Days (CASD) A ‘what matters to you most’ approach to integrated specialist care in the community.

Background: Community planned care services including MSK, podiatry and diabetes have integrated pathways that link primary and secondary care services. These services have experienced significant increases in demand affecting patient access. A new joined-up approach is required to meet the demand of an ageing population with increased complexities and comorbidities. Surrey Downs Health and Care Partnership developed an integrated approach between community services and voluntary sector partners to improve access for patients with specialist service needs.

 

Approach: MSK, Podiatry and Diabetes services have been running clinics in local leisure and community centers alongside community organisations. This collaborative approach helps people to make healthier lifestyle choices and tackles factors affecting wellbeing. Locations were carefully chosen to meet local demand and support deprived communities.

 

During a CASD, there is a ‘clinical assessment area,’ a ‘rehab corner,’ a ‘community information area.’ Patients already referred to three clinical services were invited for an appointment which began with a ‘what matters to you most conversation’ with a clinician. This appointment provides a diagnosis, treatment plan and allows signposting to community partners where further support is needed.

 

Support for managing long-term conditions was provided based on individual needs, including the use of technology. The multidisciplinary team included Physiotherapists, Podiatrists, Psychologists, Nurses, Health Care Assistants, Administrative staff, and IT support. Follow-ups were arranged through services as normal.

CASD utilises a strengths-based approach with community voluntary sector partners interacting with patients and families providing support for wider determinants of health. Formal and informal feedback from partners, patients and staff were collected.

 

Results: 4 CASD’s were completed across 12-months. Over 150 patients from waiting lists were invited to each CASD with > 80% attendance rate. Outcomes include:

• Podiatry waiting times reduced from 21 to 4 weeks for new patients.
• First-to-follow-up appointment ratios improvements six weeks post-event.
• Diabetes services have seen a reduction in wait times from 13 to 5 weeks.
• Three times more patients seen in one day for MSK.
• Proactive/Preventative gains – new referrals during CASD for diabetes team for patients on MSK/Podiatry lists.
• Opportunistic – Inviting local community members to access partners/expertise on the day for those not on an NHS waiting list.
• Digital - Group sessions delivered by technological company, supporting the management of diabetes.
• Collaborative MDT working.
• Overwhelmingly positive patient feedback.
• Two CASD delivered within a deprived area targeting health inequalities.
• Workforce activation: Innovative working with lateral thinking, promoting holistic care. Seamless coordination of care between clinicians and voluntary sector.

 

Implications: CASDs improve access to specialist services at neighbourhood level, allow a greater number of appointments to be delivered and provide access to wider support beyond healthcare by collaborating with the community voluntary sector. This model is easy to replicate and has the potential to empower more people to take greater control of their own health and wellbeing, at a wider scale. The model also can be expanded to include more specialist services and other aspects of health and care support for the population.