The presentation outlines a service commissioned by the CCG within General Practice and the success it has seen over the last 12 months

1. Louise Rycroft
Care-Coordinator

2. Priorslegh Medical Centre
McIlvride Medical Practice
The Schoolhouse Surgery, Disley
Bollington Medical Centre
33,000 patients
Our elderly population is 50%
higher than the National
average

3. “Vulnerable patients who
may need extra support”
Patient Criteria

4. • To support and coordinate care for patients with complex medical
conditions who are discharged from hospital.
• Making contact with outside agencies on behalf of the patient should
it be required.
• To improving the quality and efficiency of the current discharge
processes.
• To make better uses of resources in Primary Care and the community.
• To develop better partnerships working across the peer group and
across agencies.
• To alleviate any worries or concerns a vulnerable patient may have
once home aiding their recovery.
Our Aims

5. • Discharges from GP surgery
• Clinicians who have visited patients and feel extra
support is needed for the patient or their family/carer
• Friends and family of patients expressing concern
The care coordinator will then make contact with the
patient within 3 days.
Referral Process

6. Care Coordination Input
GP Visit
Referral to Community Matron District Nurse Visit
Ambulance Booking
Find out appointment details
Referral to Macmillan Nurses
Organise Respite
Help organising carers
Providing telephone numbers Referral to Social Services
Help with medication
Carer’s Support Signposting to voluntary services

7. The wider team…
I n t e r m e d i a t e C a r e
Pa t i e n t J o u r n e y Te a m
G P S u r g e r i e s
M a c m i l l a n N u r s e s
D i s t r i c t N u r s e s
C o m m u n i t y Ph y s i o / O T
C o m m u n i t y M a t r o n s
C a r e A g e n c i e s
Vo l u n t a r y O r g a n i s a t i o n s
S o c i a l S e r v i c e s – S t o c k p o r t , M a c c l e s f i e l d ,
W i l m s l o w, D e r b y s h i r e a n d H o s p i t a l Te a m

8. Case
Studies

9. • Mr S is a carer for his wife
who has Alzheimer's Disease.
• He is managing her care by
himself and is happy to
continue to do this.
• He was concerned about what
to do/who to contact in an
emergency.
• We have provided him with a
list of local agencies who he
can contact should he need to.
• We make contact once a week.

10. • Mr H lives alone and has memory
problems.
• He has no family locally – his Power
of Attorney is his niece who lives in
Wales.
• He has been referred to the Memory
Clinic for a formal diagnosis.
• We liaised between the Memory
Clinic and his niece to organise this
appointment.
• We have also arranged transport for
him to attend an x-ray appointment.
• We called him regularly throughout
the morning to remind him who his
driver will be, when he will be picked
up and the reason for the
appointment.

11. Co-ordinated Care case Study – Mr Young
https://www.youtube.com/watch?v=6gF9_SKGm4M

12. Video

13. Feedback
received

14. Feedback
I’m so lucky
to have this
in my area
That’s a brilliant
idea and could be
really helpful.
Thank you!
This is so
reassuring
I think you are
both stars!
You are a god send and I am
more than impressed with
the service
This is so helpful it
will be great for me
and my husband
You’ve been
ever so
helpful, thank
you
It’s very nice
that
someone is
thinking of
me
Everything has been
sorted thank you so
much for your help.
What a fantastic
service

15. Community Matron Team
“I think the biggest benefit is that
communication has improved regarding
individual patients, and that everyone involved
is kept in the loop.”
Stephanie Hambleton &
Anne Hitchen

16. District Nurses
“I feel the service has significantly
improved the patient journey.
Working Together is a valuable
source of information for us.”
Janine Bennett
District Nurse Team Leader

17. General Practice
“I have found the service most valuable
for improving communication and
freeing up time within General Practice.
Louise & Hollie take on a lot of work that
would otherwise default to General
Practice.”
Rachel Dougan
Triage Nurse

18. General Practice
“The working together model has proven itself to be an
invaluable aid to assist the coordination of care post
discharge in an all too often disjointed system. It has also
successfully piloted a shared project across a peer group
with the associated benefits that brings.
The fact that within a very short space of time, the Working
Together project has become an accepted and valuable part
of the post discharge care, is testament to both the concept
and more importantly the staff delivering it.”
Dr David Ward
GP