What kind of community team did this PCN build?

SS9 PCN is one of them seven networks were shortlisted For PCN of the year. Developed a PCN aligned community team that collaborates with others to provide care across the region. PCN operations support manager Alex Fletcher explains more.

SS9 PCN in Leigh-on-Sea, Essex, has established a PCN Aligned Community Team (PACT) which provides comprehensive care delivery between PCN practices and other health and care providers/partners. This team covers a population of just over 57,000 patients across five GP practices.

The Fuller Stock Count report emphasized the importance and need for integrated care and collaborative working. We are proof that integrated care delivery has many benefits. This new way of working allows us to deliver holistic, patient-centered care that improves the quality of life for many vulnerable residents, eases the burden on primary care, and reduces reliance on acute services.

Our team has been successful in building strong relationships with local services and stakeholders. Efforts to overcome barriers and reach key people have created a comprehensive care network in the Leigh-on-Sea area.

The impact extends beyond our own PCN as we demonstrate our commitment to improving health outcomes on a broader scale by helping to develop similar models for other PCNs.

Purposes

Our transformation journey predates the formal founding of PCN in 2019, when there was a collective recognition that better care and efficiency could be achieved through collaboration between practices.

We launched our first project by developing a home visiting team to care for patients with urgent daily demands, recognizing that many of these patients have underlying social needs. This then led to collaborating with our local acute hospital to host MSK practitioners and piloting the first such initiative in our region. It has since spread throughout the region.

These successful efforts formed the basis for our subsequent expansions. We could see the potential of this collaborative approach to tackle other challenges in healthcare and set out to advance our integration.

Approach

A significant portion of hospital admissions were due to falls among frail residents, so we formed a team to solve this problem. The PACT team, led by head nurse Nadia Halley, identify those most at risk and carry out comprehensive home visits to address medication adherence, social care needs, mobility, in-home support and living environments related to falls.

Early identification of patients at risk means interventions can be implemented collaboratively, resulting in improved outcomes and reduced reliance on acute care services. The social prescribers on our team began taking on the follow-up of frail patients and served as the single point of contact for them. This shift has led to fewer follow-up phone calls to practices from frail patients, streamlining communication and improving continuity of care.

Relationship building began with the establishment of the core team, including PACT community care practitioner Anna Potter, PACT executive coordinator Natalie Bennett and Nadia. Nadia has strengthened relationships with a range of local services including adult social care, local mental health charity Trust Links, frailty and strength building teams, secondary care services and district nursing. These relationships facilitate productive collaborations, leading to a growing network of stakeholders committed to improving patient care.

Results

Our model has led to a significant reduction in hospital admissions for patients cared for by the integrated team, from 18% to 8% within six months. This reflects the model’s effectiveness in preventing preventable hospitalizations among frail patients.

Over the same time period, PCN practices recorded a 27% reduction in GP appointments for patients on our integrated team’s books. This demonstrates the efficiency and effectiveness of our approach to managing patient needs.

Visits from urgent care practitioners to our integrated team resulted in a reduction of more than 20 acute home visits per week for six months. This highlights the increased capacity to meet patient needs more comprehensively through our model.

Future

Our innovative approach is now being applied to the field of mental health, providing holistic support to individuals facing mental health challenges. We partnered with Trust Links to deliver a successful joint bid of £30,000 to employ a specialist coordinator.

We also created a home visiting team to support practices. This team helps practices meet the urgent health needs of patients who require home visits. By doing this, we have virtually eliminated the need for extremely frail patients (those with a frailty score of seven and above) to be seen by our acute home visiting service. Patients who are more in need of a holistic approach, that is, those with high frailty scores, multiple long-term conditions, and polypharmacy, are now cared for under this new model.

Our model optimizes healthcare delivery and improves the patient experience in society by comprehensively and proactively addressing patient needs.

Profiles between shortlisted PCNs Pulse will appear on PCN ahead of the awards night on December 6.