Leading change

Nurses and other care professionals in the Adult Services Urgent Care team at Nottingham CityCare Partnership, a social enterprise delivering community healthcare in Nottingham, worked together to share professional skills, creating a new holistic approach to delivering care to older people with long term conditions, which reduced duplication and improved patient experience.

Where to look

Nurses identified unwarranted variation within the Adult Services Urgent Care team in their response to referrals and their efficiency around assessment. Nottingham CityCare has a multi-disciplinary team for urgently assessing patients in their own home, following referral from other parts of the care system.

Prior to their holistic model being developed, despite being multi-disciplinary in nature, different teams worked in very individual ways. Each patient would have four separate assessments by a nurse, physiotherapist, occupational therapist and social worker, and they would need to keep repeating their story. Having four separate assessments then led to multiple care visits by different team members – both patients and staff were in need of a more effective and efficient way of working.

What to change

The team identified that with additional training and support to provide a holistic approach, the assessment itself could be reduced from four hours (one per specialist) to one hour, without any decrease in outcomes and a better experience for the patient. Nationally there was evidence of teams effectively supporting each other in this way, but this was anecdotal and without structured guidance or competencies.

How to change

The holistic worker model of integrated working was initially commissioned as a pilot to assess patients in their own home following referral from a GP, an ambulance team, a social care assessor or a health practitioner. It was developed to change the way that care is delivered for older people with long term conditions, avoid unnecessary admissions to hospital or care homes and provide social benefits.

The staff involved in the assessments (general and mental health nurses, occupational therapists, physiotherapists, community care officers and support workers) all agreed that while complementary some elements of their assessment procedure were overlapping. The team’s patient assessments could be conducted by one of the professionals in a single visit.

The practitioners worked together to devise a specific set of clinical competencies for what they named the ‘Holistic Worker’. Nurses were skilled up to Advanced Practitioner level in physio, occupational therapy, mental health and social care – and vice versa. This has enabled each team member to carry out a wide range of assessment criteria, and give practical help and assistance during a patient’s home visit. If more specialist intervention is deemed necessary during the assessment, a specific referral to that professional in the team can be made as appropriate.

The initial patient visit, post referral includes:

• The core assessment.
• Putting care plans in place, which cover all the relevant disciplines.
• Referral to other professionals, where more specialist intervention is required.

Adding value

• Better outcomes – The number of inter-team referrals reduced significantly and a patient has fewer visits in a timelier manner, as holistic care can now be provided by an increased number of professionals across the team, maintaining specialist skills for intervention when required. Patient care has benefited from the improved confidence levels reported by all team members, who feel better equipped to manage unexpected situations, with a deeper understanding of each other’s professions.
• Better experience – Feedback from both patients and staff has been very positive. There were fewer visits overall. Patients preferred being able to tell their story only once and felt the teams were communicating better about their care and that they were signposted to appropriate resources more effectively. More than 95% said they were satisfied or very satisfied with the intervention.
• Better use of resources – The time needed for a full patient assessment reduced from four hours to one, conducted by a single team member rather than several. This increased team capacity to complete assessments, freeing up clinical time for additional specialist services as required and streamlined the care pathway.

Challenges and lessons learnt for implementation

• The perception from some people outside the team that colleagues were being asked to ‘do other peoples’ work’ was quickly dispelled by the urgent care clinicians themselves talking positively about how it worked in practice – leading to a sharing of caseloads and significant improvements in patient experience.
• Enabling new skills for staff takes time and co-ordination. Each professional needed to attend an average two days’ Holistic Worker training (both theoretical and practical). This demands careful planning, to continue to ensure services are run safely for patients, while staff are away from clinical practice for training.
• At the outset, leadership time was devoted to getting the project started, including developing the competencies. A dedicated project manager was influential in maintaining engagement with teams and giving oversight to get things started. This time and leadership also supported the development of guidelines for the Holistic Worker role.

Watch the video about the holistic worker model

This video features a patient and staff discussing the holistic worker model and the positive impact its had on patient care:

Find out more

For more information contact:

Emma Self

Head of Professional Standards

Emma.self@nottinghamcitycare.nhs.uk