Care Home Support Team (Hillingdon Health and Care Partnership)

Having the care home support team has assisted us as a health and social care system to provide regular and prompt health support and advice to all care homes in Hillingdon.  It has ensured residents can be triaged and directed to the correct service on a daily basis preventing unnecessary attendance at hospital.

Jan Major, Head of Direct Care Provision, Provider Services & Commissioned Care, London Borough of Hillingdon

About the partnership

1. After a successful pilot starting in December 2017, the Hillingdon Health and Care Partnership (HHCP) established the Care Home Support Team (CHST) to support residents of older people’s care homes and extra care housing in the borough.
2. The multi-disciplinary team includes GPs and Care Home Matrons with wider support from a Mental Health Nurse, Care Home Pharmacist, Care of the Elderly Consultant, Dietician, Speech and Language Therapist and Tissue Viability service.
3. The service co-ordinates with existing community services such as the Care Connection Teams (CCTs), Your Life Line 24/7 and Specialist Community Nursing in order to provide holistic and appropriate care.

What has gone well

1. Geographic teams mean professionals get to know the residents they are supporting well, supporting good case management, positive relationships and good care.
2. Support is targeted to need – both at a setting level (nursing homes receive more regular visits than Extra Care schemes) and for individuals.
3. Work well with the specialist palliative care team, allowing them to shift their focus to residents who have more complex needs.

Challenges experienced and overcome

1. Coordinate My Care (CMC) is an NHS service that builds medical care around the wishes of each patient. The challenge was that not all patients had a CMC record. Matrons held ACP discussions with the resides and families and created very comprehensive CMC records.

Results

1. The service supports over 1300 residents, who have complex health and care needs.
2. In addition to acute visiting, the service is now able to provide anticipatory care for residents, with each resident benefitting from an anticipatory care plan within two weeks of being registered.
3. The service provides additional targeted support to care homes with the highest levels of call outs to the London Ambulance Service (LAS) and the highest rate of acute admissions. Matrons discuss any A&E attendances with the care homes too try and avoid unnecessary LAS call outs.
4. The service has been positively received by a range of local services, including the care homes, who have highlighted their responsiveness and value.
5. Regular Multi Disciplinary Team Meetings (MDT’s) take place led by the Care of the Elderly Consultant which enables patients with complex needs to be discussed and managed appropriately with input from relevant clinicians.

What made the difference

1. Comprehensive CMC records: the service uses a system to enable effective and personalised care planning, triaging, and escalation.
2. Good working relationships: with care homes and other services. For example, the care home matrons and the specialist palliative care team regularly assess who is best placed to support the resident and home, thereby making the best use of resource and ensuring appropriate support is focused where it is needed.