Improving Access with Cornwall Pathfinders project

Case study summary

Since 2010, general practices across Cornwall have been working with Age UK and other local volunteer agencies to improve the quality of life for older people by helping them identify ways to build their self-confidence and self-reliance, providing practical support to help them achieve their aspirations. The first scheme, in Penwith, worked with an initial cohort of 106 patients. Emergency admissions fell by 30% compared with a control group.

 

GP practices across Cornwall have been working in partnership with Age UK to connect older people with care and support in the community

Since 2010, general practices across Cornwall have been working with Age UK and other local volunteer agencies to improve the quality of life for older people by helping them identify ways to build their self-confidence and self-reliance, providing practical support to help them achieve their aspirations. This reduces dependency on health and social care, including hospital admissions.

The GP practice uses a standard risk stratification tool to identify patients who are most likely to be at risk of hospital admission. Clinicians themselves can also identify people with complex needs and frailty that they believe will benefit from additional support. The patient is referred to a Promoting Independence in People (PIP) key worker, a volunteer recruited and trained by Age UK. They use motivational interviewing techniques to engage with the patient, understand needs and set goals.

A shared management plan is drawn up for the patient, with reference to local agreements about the specific roles and responsibilities of different local health and care agencies. The plan focuses on helping the person become more independent and on how to respond in case of problems. The Age UK team pull in other services as appropriate, including training, community based activities, care and support. The PIP continues to be accessible to the patient, working very closely with the general practice team.

Impact

The first scheme, in Penwith, worked with an initial cohort of 106 patients. Emergency admissions fell by 30% compared with a control group. Patients, staff and volunteers were very positive about the approach and have contributed to spreading it across Cornwall.

It is now running in nine sites, supporting 4,000 patients. Individual patient wellbeing is consistently higher, there is a 31% reduction in all hospital admissions and a 26% reduction in emergency admissions. There has been no increase in workload for community services. GP practices report a reduction in workload.

Tips for adoption

Strong relationships were essential for getting started and making changes to the project along the way.

It is important to expect the unexpected, and allow plans to develop over time as new issues and opportunities are encountered. All partners should also be ready for the fact that this kind of programme can take time to become embedded, and that flexibility and patience will be needed.

The support and involvement of local people is essential, for recruitment of volunteers as well as maintaining effective partnerships between different voluntary groups. Time spent engaging with the public at the outset is well spent.

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