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Hertfordshire County Council

How Better Care Fund projects are making a difference

The integrated Rapid Response teams

Our Rapid Response teams are able to quickly respond to people needing immediate care.

Nurses, social workers, mental health staff, physiotherapists and occupational therapists respond to older people who are at risk of being admitted to hospital in the near future.

When the team gets a referral from the GP they contact the patient within one hour and arrange a visit. During the home visit a holistic assessment is carried out to identify, plan and address the patient’s needs. This means more people are being cared for in their own home and unnecessary hospital admissions are avoided, which frees up beds.

The St Albans and Harpenden Rapid Response team was shortlisted for a national Health Service Journal Value in Healthcare Award 2017.

 

Multi-Specialty Team approach

This initiative in West Hertfordshire brings core teams from health and social care together to coordinate the care planning of complex patients who have multiple needs.

They have a weekly multi-agency meeting to discuss referrals from GPs and other frontline staff. Those who attend include community nurses, social workers, therapists and mental health teams. They work together to consider what the patients' needs are and how they can work together to give people the best care. 

Feedback from staff across West Hertfordshire has been very positive. Staff have reported:

  • quicker referrals and responses
  • improved working relationships and communication between care groups
  • increased ability to address people's multiple needs and give personalised care
  • co-ordinated responses meaning improved outcomes for patients

 

Complex Care Premium scheme

This is an in-depth training programme for care home staff so they can deliver better care to frail elderly residents. It allows receipt of an enhanced payment rate – or Premium – for those residents.

The training gives care home staff more confidence to look after frail elderly people with complex conditions, improving their health and quality of life and preventing unnecessary and potentially distressing admissions to hospital.

Staff 'champions' taking part get up to 18 days training in 1 of 6 specialist areas:

  • dementia
  • nutrition,
  • engagement and wellbeing,
  • falls and fragility,
  • wound management
  • health (including end of life, continence, neurological and respiratory conditions).

A total of 217 champions have been trained since the programme began in 2015. Since then hospital attendances/admissions from care homes have reduced and residents’ experiences have improved by being able to remain in their care home rather than going to hospital.

The initiative won the workforce development category in the national Health Service Journal Value in Healthcare awards 2017.

 

The Impartial Assessor pilot project

This project is part of a Better Care for Care Home Residents Vanguard programme in East and North Hertfordshire.

The Impartial Assessor is a trained nurse employed by Hertfordshire Care Providers Association who works at the Lister Hospital in Stevenage to speed up admissions into care homes and reduce delayed discharges.

The Impartial Assessor carries out a comprehensive assessment of the needs of elderly hospital inpatients to see if they’re well enough to return to their care homes. They then work with the patient, hospital discharge team and care home staff to make sure the patient gets back to their care home as soon as possible.  

21 care homes have so far used the new service and figures already show a reduction of one/two days in hospital for elderly care home residents.

Read the article at the EN Herts Vanguard website for more information on the pilot project.

 

 

Using technology to give better care

We’re working to enable and improve data sharing between health and social care organisations to avoid people having to tell their story more than once. We’re also making use of advances in technology to understand the health needs of Hertfordshire residents better.

We’re rolling out a risk stratification tool to GPs, which uses several data sources to identify the top 20 patients in a GP practice most at risk of emergency admission. By using this we can target interventions more precisely and prevent people going into hospital when they could be treated more effectively at home.