Tunstall on onsite (care home) access to clinical records for GPs and matrons


NHS Calderdale Clinical Commissioning Group (CCG) serves a population of 213,000 people, almost 17,000 of whom are currently living with a long-term condition (LTC). As with many regions of the UK, Calderdale has an ageing population and by 2018 it is estimated that 18% of the population will be aged 65 or above. Calderdale also has a higher rate of older people living in care homes compared to other regions across England, expected to rise from 982 in 2012 to 1,205 by 2020.

What challenge did we seek to solve

This ageing population and the increasing number of people with LTCs is likely to have a considerable impact on health and social care services. In anticipation of these increasing demands on resources, NHS Calderdale CCG developed a commissioning plan for 2012/13 with a clear objective to establish a more consistent and sustainable model of care for older and vulnerable individuals in Calderdale; a truly person-centred approach which would best meet the needs of people with long-term health and care needs, and help to make efficient use of NHS resources. The Quest for Quality in Care Homes pilot was developed, which combined a Multi-Disciplinary Team, real-time access to live clinical records for GPs and Quest for Quality in Care Homes Matrons, and telecare and telehealth systems to improve the quality of care and help to reduce avoidable hospital and GP visits.

What did we do

The Quest for Quality in Care Homes pilot aims to address the variations in practice across care homes, supporting the delivery of consistent, efficient, proactive care by upskilling and empowering staff. More than half of the care homes in the area (twenty four) have signed up to be part of the pilot so far. A key focus for the pilot has been to reduce admissions to hospital from the residents of care homes, typically for urinary tract infections, respiratory infections, falls and fractures. The pilot provides additional support to care home staff to help improve outcomes and prevent unnecessary hospital admissions. The project has been implemented in three key phases:

1) Providing access for GPs and Quest Matrons to real time clinical records through the provision of an IT system in the care homes. This enables GPs and Quest Matrons to access their patients’ medical records, enabling ‘joined up’ care and informed decision making.

2) Development of telecare and telehealth systems to support prevention, diagnosis and treatment. Tunstall has provided advanced telecare and telehealth solutions to support homes to improve the quality of care provided and proactively deliver care to residents to help prevent deterioration and exacerbation of chronic.

3) Investment in a Multi Disciplinary Team (MDT), providing an integrated social and clinical approach to support anticipatory care planning. As part of the Quest for Quality in Care Homes model, NHS Calderdale CCG has commissioned Calderdale and Huddersfield NHS Foundation Trust (CHFT) to provide an integrated professional and clinical Multi-Disciplinary Team.

Outcomes achieved

Using technology as part of a multi-disciplinary approach to maximise efficiencies across health and social care economy.

Enabling people to live healthier and happier lives, with greater control of their own care.

Services becoming more integrated around the patient.

Results for the second year of the service in 2015/16 showed:

• Hospital bed days used decreased by 68% year-on-year

• GP care home visits reduced by 45% compared to non-Quest homes

• Emergency admissions down 26% year-on-year

• The cost of hospital stays has reduced, saving £799,561 in a year

Future plans

- This new model of care is replicable

- This innovative approach aligns with Calderdale's Care Closer to Home programme and our status as a Vanguard site for NHS Five Year Forward View

- We will continue to expand our single access, mutli-disciplinary system to move healthcare into the community

- The aim is to ensure the right skills and services are in the right place at the right time.

Contact details: Alison.rogan@tunstall.com

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