An award-winning GP practice in Gateshead has halved A&E visits for frail elderly patients using joined-up technology from EMIS Health.
Oxford Terrace and Rawling Road Medical Group (OTMG-RR), is using personalised care planning and shared records via EMIS Web to enable their complex care team to care for those at risk of hospital admission.
The GPs identified 2,500 patients who did not need immediate care from community matrons or GPs but who were at risk of hospital admission because of broader health or social issues associated with age and frailty. Only 300 of them would have been captured by the unplanned admissions DES.
The practice had received around eight discharge letters every day – it now receives just three or four a week.
South Tyneside NHS Foundation Trust seconded an older persons’ specialist nurse (a post now substantive in the practice) to co-ordinate and implement care plans. As well as GPs, the team also includes nurses, a primary care navigator, a practice-based occupational therapist and community matrons. Using EMIS Web, all of the healthcare professionals in the team can write and update care plans.
Practice manager Sheinaz Stansfield explained: “It’s all about teamwork. For example, our primary care navigator and healthcare assistants will call at-risk patients and identify health and social factors that could affect their health; an individual could be feeling isolated and not eating properly – a situation which could make them more susceptible to infection.
“Knowing that, the broader team are able to suggest action – including the best people to take action – to prevent the situation from escalating. It might be that the district nurse could time a visit to check what’s on the menu. It’s about moving from reactive treatment to proactive and preventative care.
“Previously this was a challenging task. Community services teams, for example, were on a different IT system entirely which added extra administrative layers and delays to updating patient records. Now we all sit down and have regular planning sessions. It is patient-centric care made a reality.”
She added: “The success of the scheme has also enabled us to make business cases – backed by data – for additional support to our CCG. For example we were able to show that an in-practice occupational therapist would actually save time, resources and money by working with patients, maintaining independence and reducing hospital admissions or care home admissions.”