AT A GLANCE
THE CHALLENGE
Hyde Primary Care Network (PCN) is in an area of Greater Manchester with the third highest rate of emergency hospital admissions and the highest standardised rate of mortality in England. The PCN’s number of dementia patients is higher than the national average.
There were 1,694 emergency admissions in 2016/17 from a dementia register of 1,939 patients. Dementia patients living in their own homes were receiving significantly less proactive care than those in care homes. Collaboration between primary, secondary and mental health care services could be improved.
WHAT THEY DID
The CLEAR project focused on dementia patients living in their own homes. The team conducted interviews with 14 members of local health and social care teams working in dementia care. Six months of data from the PCN’s eight GP practices was collated and analysed (July to December 2021). Analysis showed that 354 dementia patients living at home had 15,838 GP appointments during the six months compared with 7,179 appointments for the 310 dementia patients living in care homes.
CLEAR RECOMMENDATIONS
To improve collaboration between different care providers and the inequity of care received by patients at home, compared with those in 24-hour care, the team recommended launching a new dementia case management service.
The new multi-disciplinary team with a dementia case manager would take a proactive and person-centred approach to supporting patients living at home with the aim of optimising their health and reducing the need for GP appointments and hospital admissions.
Nurses and care co-ordinators would be part of the team, based at the PCN’s hub, serving all eight practices on weekdays with an on-call rota for out-of-hours contact from health and social care professionals.
FORECAST IMPACT
By proactively caring for dementia patients living at home, their wellbeing would be improved with a lower risk of poor health in the future. Better planned and person-centred care could lead to a 50% reduction in GP appointments, generating annual productivity savings of £617,682. The cost of the new model of care would be covered by a 14.5% reduction in GP appointments.
The release of clinical time – equivalent to two full-time GPs per year – would enable the PCN to benefit from £290,000 of payments under the Enhanced Access Plan designed to increase the range of bookable GP appointments during the evenings and on Saturdays. The new service is likely to lead to reduced emergency department attendances with productivity gains for secondary care. The PCN is implementing the model which is due to go live in April 2023.
