How this PCN created a community team

SS9 PCN is one of the seven networks shortlisted for PCN of the year. It has developed a PCN-aligned community team that collaborates with others to provide care across the area. Alex Fletcher, PCN operations support manager, explains more.

SS9 PCN in Leigh-on-Sea, Essex, has created a PCN Aligned Community Team (PACT), which is comprehensive care delivery between PCN practices and other health and care providers/partners. This team covers a population of just over 57,000 patients across five GP practices.

The Fuller Stocktake report highlighted the importance and need for integrated care and collaborative working. We are proof that there are many benefits to integrated care delivery. This new way of working allows us to provide holistic, patient-centred care that has enhanced the quality of life for many vulnerable residents and it has eased the burden on primary care and reduced reliance on acute services.

Our team has excelled in building strong relationships with local services and stakeholders. Their efforts in breaking down barriers and reaching out to key individuals have created a comprehensive care network in the Leigh-on-Sea area.

The impact extends beyond our own PCN as we assist in developing similar models for other PCNs, demonstrating a commitment to improving health outcomes on a broader scale.

Aims

Our journey of transformation predates the formal establishment of the PCN when, back in 2019, there was a collective recognition among practices that better care and efficiencies could be achieved through collaboration.

We initiated our first project by developing a home visiting team to provide care for patients with urgent on-the-day requests, recognising that many of these patients had underlying social needs. This then led to collaborating with our local acute hospital to host MSK practitioners, piloting the first such initiative in our area. Since then, it has expanded across the region.

These successful endeavours laid the groundwork for our subsequent expansions. We could see the potential of this collaborative approach in addressing other healthcare challenges and set out to further our integration.

Approach

A significant number of hospital admissions were due to falls among frail residents, so we established a team to address this issue. The PACT team, led by lead matron Nadia Halley, identifies those most at risk and conducts comprehensive home visits to address medication compliance, social care needs, mobility, domestic support, and living environments related to falls.

The early identification of patients at risk means that interventions can be implemented collaboratively, resulting in improved outcomes and reduced reliance on acute care services. Social prescribers within our team have begun undertaking follow-ups for frail patients, serving as a single point of contact for these individuals. This shift has resulted in reduced follow-up telephone calls to practices from frail patients, streamlining communication and improving continuity of care.

With the core team established, including PACT community care practitioner Anna Potter, PACT admin coordinator Natalie Bennett, and Nadia herself, relationship-building began. Nadia fostered relationships with various local services, including adult social care, local mental health charity Trust Links, frailty and strength improvement teams, secondary care wards, and district nursing. These relationships facilitate productive collaborations, leading to a growing network of stakeholders committed to improving patient care.

Outcomes

Our model led to a significant decrease in hospital admissions among patients cared for by the integrated team, dropping from 18% to 8% within six months. This reflects the model’s effectiveness in preventing avoidable hospital admissions among frail patients. 

Over the same time frame, PCN practices recorded a 27% reduction in GP appointments for patients on the books of our integrated team. This demonstrates the efficiency and effectiveness of our approach to managing patient needs.

Transitioning emergency care practitioner visits to our integrated team resulted in a reduction of more than 20 acute home visits per week over six months. This highlights the increased capacity to address patient needs more comprehensively through our model.

Future

Our innovative approach is now being rolled out in mental health, providing holistic support to individuals facing mental health challenges. We partnered with Trust Links to put in a successful joint bid for funding of £30,000 to employ a specialist coordinator.

And we have also developed a home visiting team to support practices. This team helps practices meet the urgent health needs of patients requiring home visits. By doing this, we have nearly completely cleared the need for highly frail patients (those with a frailty score of seven and above) to be seen by our acute home visiting service. Patients with a higher need for a holistic approach – that is, those with a high frailty score, multiple long-term conditions, and polypharmacy – are now cared for under this new model.

By addressing patient needs comprehensively and proactively, our model optimises healthcare delivery and enhances patient experience within the community.

Profiles of the shortlisted PCNs will feature on Pulse PCN in the run up to the awards night on December 6.