An ambitious project which is transforming how community-based care is delivered is already creating a positive impact on the lives of Shropshire people, says NHS Shropshire Clinical Commissioning Group (CCG).
Shropshire Care Closer to Home (SCCtH) is a programme of work dedicated to improving the health and social care outcomes for people over the age of 65. It aims to help people get the right care and support they need before they become ill so that they stay well for longer and potentially avoid an unnecessary admission into hospital.
Shropshire Care Closer to Home is bringing health, mental health, social care, dementia and living support to people in their local community, and even into people’s own homes. It is a proactive programme of care that helps to keep people as well as possible, and in their own home, for as long as possible.
Between August to October 2019 the teams prevented 30 ambulance callouts, 46 patient trips to A&E, 44 hospital admissions, and 12 hospital readmissions through alternative and preventative care, and support in the community and at home.
The work of Shropshire Care Closer to Home is providing care for those people who may need additional, specialist support to help them stay well for longer in their own home. As an example of this, the programme has helped to provide specialist beds, help with wound dressings, and additional support from care agencies. This care is provided by a range of healthcare professionals working in a team and includes community matrons through to social workers.
Partners involved in the programme include Shropshire Council, Shropshire Community Health NHS Trust, Midlands Partnership Foundation Trust (MPFT), and charity organisations such as the British Red Cross, Age UK, and Alzheimer’s Society.
The programme of work covers many aspects including lower levels of preventative care and support, such as nursing, dementia support and therapy. It also covers higher level responsive services; such as Rapid Response and Hospital at Home that provide intensive care in the community.
In the areas of the programme that are already up and running, two elements have achieved particular successes to date.
A ‘Frailty Intervention Team’ based in the hospital A&E department, is a small specialist group that provides a fast-track service to get frailer patients over 75 quickly assessed, treated and discharged safely back into their homes or an appropriate care setting.
This Frailty Intervention Team is a nationally recognised scheme and has been so successful that it is now running five days a week at both the Royal Shrewsbury Hospital and Princess Royal Hospital in Telford.
A pilot scheme is also underway, as part of a separate element of the programme, in eight areas of Shropshire and is led by a team of health and social care professionals to test out a new way of reaching people sooner and providing care and support in a different way.
These teams are tasked with developing tailored care plans by pulling information from across health and social care providers involved in the programme and ensuring wraparound care for the individual, which could include living support as well as nursing and therapy.
The teams, who have been in place since late August, have already worked with and are supporting more than 200 people. Of these, 132 have been helped to stay out of hospital with preventative care and support provided in the community or in their own homes.
Following the pilot period, to trial this new way of providing care, planning will commence to roll this service out across the rest of the county.
Dr Julian Povey, Chair of Shropshire CCG, said: “This is a massive transformation programme and already we have come a long way in creating a new vision for the future of healthcare in Shropshire.
“By working with partners and bringing care closer to home we have seen a number of successes since the programme’s beginnings which are making a real impact on the care local people receive.
“We look forward to what 2020 holds in the next stages of this exciting programme.”
For further information on the Shropshire Care Closer to Home Programme please visit: www.shropshireccg.nhs.uk/get-involved/engagement-and-consultation/shropshire-care-closer-to-home.