Connecting Care Hubs - where health, social care, housing and voluntary and community organisations work side-by-side - are helping those people most at risk stay well and out of hospital.
Focusing on crisis intervention, the Hubs prevent avoidable hospital admissions whilst supporting services to enable people to be discharged from hospital as soon as they are well enough.
The Hubs in Wakefield, West Yorkshire, have multiple agencies working together, all under one roof, to seamlessly support patients with health and/ or social care needs who could otherwise receive fragmented care, with multiple referrals and handovers.
This means that people only tell their story once, usually to their GP, who refers them into the Hubs to receive joined up care and support, ensuring they receive the right care, at the right time, in the right place and provided by the right person.
Once referred and assessed, the person might be visited by a nurse, occupational therapist, physio, social care worker, voluntary worker, housing officer or mental health worker.
In six months they’ve seen almost 2,000 people including 636 urgent referrals.
It is the latest example of the success of 14 integrated care systems (ICS) now operating across the country, offering people a seamless service by partnership working between the NHS, local councils, housing and the voluntary sector.
West Yorkshire and Harrogate Health and Care Partnership recently became an ICS after a vote of confidence in its strong local leadership, partnership working and ambitious plans to strengthen primary care.
Jo Webster, WY&H Clinical Commissioning Group (CCG) Lead and Chief Officer at NHS Wakefield CCG, said: “People only want to tell their story once and then they want a solution. Many elderly people don’t have a single medical condition or social care problem, they need a package of help which meets their needs and what we’ve done in Wakefield and in other areas of WY&H is to provide that.
“If someone has fallen for example and might be living on their own and socially isolated, they can be referred into the Hub for support with all of these factors, which may be impacting on their health and wellbeing.”
Between 2015 and 2035, the numbers of older people with four or more diseases will double and a third of these will have mental-ill health.
One in three people admitted to hospital as an emergency has five or more health conditions, up from one in ten in 2006/7.
As well as the patient benefit, reducing excess cold in homes to an acceptable level would save the NHS around £848 million a year and reducing all falls in the home could save it £435 million.
In response, we need a system that supports an individual’s complete needs rather than treating each illness or care problem in isolation. The Hubs view people holistically and support individuals with complex health and/ or social care needs to achieve better health outcomes, closer to home.
Funded jointly by £5.9m from the NHS Wakefield CCG and Wakefield Council, the Hubs relieve pressure on primary care as GPs can potentially just ring one number or complete one e-referral for a person with multiple needs.
Previously, they would have needed to call several different agencies separately which could be time consuming and sometimes difficult, due to frequent changes in service, numbers and eligibility criteria.
Dr Phil Earnshaw, local GP and Chair at the NHS Wakefield CCG, said: “This has been fantastic for primary care because it saves so much resource. We have more time to use our clinical expertise because there is a wider team supporting us.
“All we need to do when we have a patient who is appropriate for the service is refer into the Hubs and we know their needs are taken care of. The new electronic care record system we’ve introduced means we can all see the patient’s record and that all individuals involved in someone’s care know what’s happened to that person from the beginning to the end of their journey.”
A cornerstone in delivering a seamless service was the electronic care record, known as the Personal Integrated Care (PIC) file, which went live in Wakefield in December 2017.
Merran McRae, Chief Executive at Wakefield Council, said: “The new electronic care record has been key to realising the potential of the Hub model. Patients are at the heart of our services, and the new system means we can work more effectively as a partnership to meet their needs. By allowing all the professionals, including social workers, to see the person’s summary records, teams can work more closely together and give people the care they need to live independently in their own homes and communities.”
The PIC was originally piloted across a small number of GP practices and is currently being rolled-out to all other practices in Wakefield. All GPs can refer via telephone into the Hub even if they are not live with the PIC File yet.
In the Hub, a team of social care and health professionals sit together with coordinators in one office and triage referrals to the right place or person. The social care and health professionals can do both roles sometimes doing triage work and sometimes visiting patients. They monitor patients keeping everyone up-to-date with progress.
An urgent care team sits with them and can go to any patient needing rapid care, for example providing mobility equipment that day which may prevent them needing to go into hospital.
They are supported by a Late Visiting Service run by community matrons who see mainly elderly, house-bound patients needing an urgent same day home visit. Patients get seen sooner in the day, preventing health problems getting worse which enables the patient to stay at home and avoid a hospital admission.
In eight months, the late visiting service has seen almost 400 people and prevented many of these from going to hospital. Community matrons can also refer into the Hub if the person they visit needs extra support for other health, wellbeing or social care issues.
Debbie Newton, Director of Community Services at the Mid Yorkshire Hospitals NHS Trust, said: “The Hubs have been at the forefront of the health and social care integration programme, known as Connecting Care+, in Wakefield.
“It’s fantastic to see how the Hubs can improve patient experience, whilst also impacting positively on primary and secondary care activity.”