Abstract
Providing care for residents living in care homes who are frail and vulnerable, has long been a challenge in London. For patients with complex needs, the onus is usually on them and their carers to navigate an intricate health and social care system with multiple points of entry each of which may be accompanied by their own geographical, digital and commissioning barriers. Within the London Borough of Ealing, delivery of primary care services including the enhanced specification, designed to promote personalised, outcome-focused care for people living in care homes, is centred around a single GP practice. With a caseload of nearly 1200 patients (age range 22-109) residing across 38 nursing, residential, learning disability and mental health specialist homes, the practice known as the ‘Care Home Service’ delivers planned and unplanned care, 12 hours a day, 365 days a year. Holistic delivery of care is achieved through a multidisciplinary team of clinicians including doctors, advanced nurse practitioners and pharmacists.
Vision:
•Excellence in care home medicine; proactive care planning and chronic disease management
•Continuity of high quality, standardised primary care
•Reduction in admissions to hospital and reduced length of stay
•Upskilling of care home staff
•Integrating pathways across the spectrum of care
This vision is realised through primary care support provided by the practice as well as specialist mental and physical health support available as a result of the practice’s position within Ealing Community Partners- a group of NHS, Local Authority commissioned and voluntary sector organisations working together since 2019 to deliver community health and care services for people in the Borough. Services include:
•Access to advanced care planning through the palliative care charity Marie Curie
•Out-of-hours enhanced GP support provided by a clinically-led, social enterprise provider of urgent and primary care services to the NHS.
•Care Home In-reach Liaison Service established in 2023 to support patients with challenging behaviours
Results:
•Planned care needs met within 48 hours (97%) and unplanned care within 2 hours (100%)
•Routine medical assessments (97%) and medication reviews provided every 3 months (100%)
•Patient care plan reviews conducted as a minimum twice a year (95%)
•Significant reduction in calls to emergency services- lowest in region
•When admitted to an acute hospital, the majority of patients stayed for less than 1 day (2022 to present)
•Support for residents with challenging behaviours in their current home setting
•Respect for the patient’s preference regarding place of death when terminally ill
Implications:
•The Care Home Service is a trailblazer in London- providing a responsive and adaptive service to improve quality of life for frail populations.
•Investment in care provision for patients living in care homes at primary and secondary care levels within the NHS system is a significant contributor to a reduction in acute system pressure.
•Reduced acute hospital admissions ensures patients are treated in a familiar environment reducing impact on cognitive functioning, mental health and maintaining connection to carers.