Dataset Information

A long way from Frome: improving connections between patients, local services and communities to reduce emergency admissions.

ABSTRACT:

Background

Low socio-economic status can lead to poor patient outcomes, exacerbated by lack of integration between health and social care and there is a demand for developing new models of working.

Aim

To improve connections between patients, local services and their communities to reduce unscheduled admissions.

Design and setting

A primary care cluster with areas of high deprivation, consisting of 11 general practices serving over 74,000 people.

Method

A multi-disciplinary team with representatives from healthcare, local council and the third sector was formed to provide support for people with complex or social needs. A discharge liaison hub contacted patients following hospital discharge offering support, while cluster pharmacists led medicine reviews. Wellbeing Connectors were commissioned to act as a link to local wellbeing and social resources. Advance Care Planning was implemented to support personalised decision making.

Results

Unscheduled admissions in the over 75 age group decreased following the changes, equating to over 800 avoided monthly referrals to assessment units for the cluster. Over 2,500 patients have been reviewed by the MDT since its inception with referrals to social prescribing groups, physiotherapy and mental health teams; these patients are 20% less likely to contact their GP after their case is discussed. An improved sense of wellbeing was reported by 80% of patients supported by wellbeing connectors. Staff feel better able to meet patient needs and reported an increased joy in working.

Conclusion

Improved integration between health, social care and third sector has led to a reduction in admissions, improved patient wellbeing and has improved job satisfaction amongst staff.

SUBMITTER: Withers K

PROVIDER: S-EPMC11330060 | biostudies-literature | 2024 Aug

REPOSITORIES: biostudies-literature

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Publications

A long way from Frome: improving connections between patients, local services and communities to reduce emergency admissions.

Withers Kathleen K Pardy Karen K Topham Lynne L Lee Rachel R Ghanghro Amir A Cryer Hazel H Williams Huw H

BMC primary care 20240817 1

<h4>Background</h4>Low socio-economic status can lead to poor patient outcomes, exacerbated by lack of integration between health and social care and there is a demand for developing new models of working.<h4>Aim</h4>To improve connections between patients, local services and their communities to reduce unscheduled admissions.<h4>Design and setting</h4>A primary care cluster with areas of high deprivation, consisting of 11 general practices serving over 74,000 people.<h4>Method</h4>A multi-disci ...[more]

PMID: 39154009

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Dataset Information

A long way from Frome: improving connections between patients, local services and communities to reduce emergency admissions.

Background

Aim

Design and setting

Method

Results

Conclusion

Publications

A long way from Frome: improving connections between patients, local services and communities to reduce emergency admissions.

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