South Gloucestershire Clinical Commissioning Group (CCG) and Sirona care & health have been shortlisted for a prestigious national award for their ‘joined-up’ approach to supporting the area’s most vulnerable local residents.
The organisations are in the running for the national Healthcare Transformation Awards, supported by NHS England, for their innovative ‘multi-disciplinary team’ approach to health and care for people who are at most risk of hospitalisation.
Under the approach, health and care professionals including community nurses, therapists, GPs and social workers meet regularly as a single team to identify vulnerable residents who might need extra help and plan a comprehensive, personalised care package based on an individual’s unique needs.
This tailored approach has proven extremely effective at preventing the type of crises that can lead to emergency hospital admissions. There was no increase in the number of South Gloucestershire residents attending a hospital Emergency Department between April 2016 and January 2017, compared to the previous year. This is despite an increase of around 5% nationally during this period.
Dr Jon Evans, South Gloucestershire CCG Lead for Long-Term Conditions and End-Of-Life Care, said, “We are delighted that this work has led to such great outcomes for our patients and has been recognised at a national level in this way.
“We know it is vitally important that we help keep patients out of hospital wherever possible and provide appropriate support for them to return home. This presents them with the quickest recovery after injury or illness and will make the greatest improvement to their quality of life.
“By working in teams based around groups of GP Practices, we are able support the individual needs of each patient with a team of experts including GPs, community matrons, physiotherapists, social workers and district nurses. These multi-disciplinary teams put the individual at the centre of care and provide an effective integrated team of health and care professionals looking at the very best way we can treat the patient.”
Jenny Theed, Director of Operations and Nursing for Sirona care & health, said, “The development of multi-disciplinary teams was a key part of our proposal for providing services in South Gloucestershire from 2014 and we are delighted that it has now become an established feature of joined up primary and community care in South Gloucestershire. The teams, which include some of our most experienced practitioners, discuss the care of people with complex needs currently in hospital and close to discharge, people nearing the end of their life, and those at home identified as potentially at risk of a health crisis.
“Our staff were praised for the Outstanding Care they give to all those who need us in our recent Care Quality Commission report and we were pleased the inspectors also described our multi-disciplinary working as outstanding.
“The additional involvement and support from our social care, mental health and voluntary sector colleagues ensure a truly joined up service for individuals. This integrated approach not only makes sure individuals get the right support and treatment in the community to prevent them being admitted to hospital but has also supported the introduction of new and innovative ways of working and better care for those who need us. It is a holistic approach to provide truly wrap-around care and reduce the risk of individuals becoming unwell or being admitted to hospital.”
The new approach is now being considered by other healthcare teams in the region and has the potential to help patients outside of South Gloucestershire.
The healthcare teams will join other healthcare experts from across the country for the award ceremony, which will take place in The Crown Plaza London Dockland on 28 June.
You can find more information on multi-disciplinary teams in this Sirona care and health video.