- ‘’Funding for the Care Home Alignment is no longer available from 30.09.2017, moving forward it is expected that the alignment continues to naturally progress as suggested by the Coalfields pilot , over the next 18 m period. The continued process will be largely dependent on a proactive approach by both practices and care homes to ensure that residents continue to be registered with the named aligned practice.
- The focus for EPC during autumn is the development of the GP element in to the current RAH service with the aim of supporting complex clinical decision making and releasing capacity within the overall model of out of hospital care. Following an engagement event with stakeholders and an extensive mapping exercise it was agreed that SGPA and STFT would work collaboratively on the enhancement of the current RAH service in order to release capacity, increase the volume of home visits and contribute to the reduction of non-elective hospital admissions. Dr Jane Halpin who produced the initial scoping report and Karen Swaile, Programme Lead EPC are based within Leechmere during September, they will concentrate on the recruitment of a GP lead and Gps /GP practices to provide the required cover. The GP’s will be responsible for ( among other things), triage support, telephone advice, home visits and clinical supervision. The core hours will be between 0800-1800 hrs Mon-Friday.
Following successful recruitment work will be directed towards developing protocols , pathways and operating procedures. The plan is to have the service operating in time to support winter pressures, a phased roll out will be considered so as not to cause an unpredictable surge in activity.
- The clinical post-discharge service following an unplanned medical admission, continues to build up momentum again following the summer break with some interesting results. An interim evaluation is planned and will be shared in October. There are discussions around how the developing Falls strategy may link in to this service, as well as how the service is assisting with the identification and proactive intervention for those people who attend hospital on a unplanned but regular basis.
- 8 practices in Sunderland have signed up to use the Patient Activation Measure tool ( PAM tool) to improve the success of changing behaviours in those patients with long term conditions. With the growing need to support people to self-manage and the associated requirement for health systems• 8 practices in Sunderland have signed up to use the Patient Activation Measure tool ( PAM tool) to improve the success of changing behaviours in those patients with long term conditions. With the growing need to support people to self-manage and the associated requirement for health systemsto change how they deliver care, there is an increasing interest in Patient Activation and Health Coaching. Patient Activation is ‘an individual’s knowledge, skill, and confidence for managing their health and healthcare’ (Hibbard et al 2005). Research consistently finds that people who are more activated are engaged in more healthy behaviours and self-management activities, and that increasing activation can reduce burden on the health and care system and support people to enjoy higher levels of health and wellbeing.
This primarily nurse -led initiative is being incentivised by the EPC budget for the additional work required and practices are reminded to submit the first invoice on completion of the proposed plan in September and then the final balance after 3/4 months of the plan initiation, Dec/January.’’