A Derbyshire primary care network (PCN) is taking the first steps in delivering a more proactive approach to care.
Arch PCN (covering Alfreton, Ripley, Crich and Heanor) has appointed an elderly care liaison officer, Cheryl Stanley, pictured above, to visit people in their own homes to take a more holistic assessment of an individual’s health and care needs.
Cheryl, a former healthcare assistant, began her visits in May 2022 and will be taking referrals from across the nine GP practices in the three neighbourhood areas.
Becky Tomlinson, Arch PCN Operations Manager, explains: “There is a huge need to provide more proactive care to support people to live as independently as possible. We have been very pleased with the launch of our acute home visiting service but that works on a reactive basis, dealing with frail, housebound people with medical problems, sometimes when they are very unwell. This new service attempts to catch people before they have a crisis.”
Cheryl, who is working 30 hours per week in this new role, adds: “GPs and nurses simply do not have the time sometimes to spend with people to listen and understand all of their health and wellbeing needs. I think that I am therefore in a privileged position to sit down with someone in their own home and build up a rapport with them. The time needed varies – from about half-an-hour to more than two hours on one occasion – so I can fully understand what a person needs to help them feel safe and as independent as possible.
“Recently, I went to an older lady living on her own in Alfreton who had developed a high level of anxiety about falling. She had carers visit during the day but inbetween times would not go to the toilet or get any drink or food, for fear of falling, and as such was spending long periods of time in her chair. I was able to look at ways of getting her mobilised, seeing how we could get her to a falls clinic and getting a visit from a physio to provide her with appropriate exercises.”
Arch PCN is currently revising how Cheryl identifies and works with her caseload of referrals. Initially by using an elderly frailty index she was being referred to GP practice patients who were known to and already in receipt of a number of health and care services. However, the aim is to link her up with individuals who might not be on the radar of so many services, so that an intervention, or interventions, can take place before the presenting situation escalates further. In this way, Cheryl can work with individuals to better understand their specific needs and address them, through a variety of ways including completing respect forms, organising support equipment, linking up with befriending or respite services or referrals to other services.
Becky adds: “The type of people we are looking for are the ones who have gone downhill since Covid, maybe had a couple of falls which no-one has picked up and become anxious, someone with non-urgent medical needs who would really benefit from a home visit. We must say that we’ve been really lucky with Cheryl’s appointment. We weren’t entirely sure what we went out to advert for but we’ve got far more than we were planning.”
Arch PCN plans to take this new elderly care liaison service to the Place Alliance and open it up for other services in Amber Valley beyond the local GP practices, such as East Midlands Ambulance Service and DHU111, to be able to refer into.
For further information about the service and Arch PCN, please contact Becky Tomlinson, Operations Manager, via email r.tomlinson2@nhs.net