Reducing hospital admissions through proactive care planning and integrated working

NHS Confederation
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A case study of a primary care home model developed by the National Association of Primary Care (NAPC) and trialled by Thanet Health Community Interest Company. The model consists of an integrated nursing team providing an enhanced frailty pathway and an acute response team offering a range of treatment and personal care support to keep people out of hospital. The teams, comprising a GP, nurses, healthcare assistants, physiotherapist, occupational therapist, voluntary care and care agency, work closely with social services. They assess patients and put a package of care in place to enable them to remain at home or be discharged. Health and social care coordinators were also brought into GP surgeries to provide non-clinical support to patients, and GP surgery hours extended to include weekends and bank holidays. Initial findings show that the frail elderly are receiving better care out of hospital with fewer visits from different staff and being admitted to hospital less frequently. Over a ten-week trial period in 2016/17, non-elective admissions fell by 155 compared to the same period last year, suggesting potential annual savings of almost £300,000. Medication reviews have also brought down prescribing costs and reduced unnecessary treatment. Integrated teams and an integrated leadership board means all organisations are working much more closely together. There has also been a 19 per cent total drop in healthcare of older people (HCOOP) admissions over this period. (Edited publisher abstract)

Subject terms:
integrated care, primary care, hospital admission, multidisciplinary teams, very old people, care planning, case studies;
Content type:
practice example

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