New Models of Care – Livewell South West

Case study summary

A new model service designed, to improve quality of care for patients in nursing and residential homes. The service will deliver a weekly clinical pharmacist visit to each home along with a joint GP/Pharmacist visit every four weeks.


Evidence shows that care home residents are among the most vulnerable people in our society with complex needs that often include multiple long term conditions and advanced frailty which cannot be met by primary care within the GMS contract to the level required to ensure good quality of care. Care home residents are unable to attend their local pharmacy for treatment of minor ailments, or attend their primary care practice, resulting in frequent visits to the care home from GPs, with frequent and multiple prescribing interventions. They also have a higher than average use of emergency and urgent care services, including the South Western Ambulance Service (SWAST) and Devon Doctors.

Patients in nursing and residential homes are currently underserved within the current general practice contract.  GP care to residents in nursing and residential homes is often limited to visits on request, with little continuity of care.  Each care home usually has residents registered with a variety of GP practices leading to fragmented inconsistent care. In addition, polypharmacy is often one of the main causes of emergency admissions. Adverse drug events account for approximately 6.5% of all hospital admissions, but more in older people, leading to increased hospital stay and significant morbidity and mortality.

Livewell proposed a change that challenged the current model, which recognised the vulnerability and heightened medical risk for this frail group of patients.


A new model service has been designed, to improve quality of care for patients in nursing and residential homes. The service will deliver a weekly clinical pharmacist visit to each home along with a joint GP/pharmacist visit every four weeks.

The scope of the service includes the joint working innovation for care homes to address frailty and ensure effective prescribing. The model is for a multi-disciplinary integrated healthcare team to care for patients in nursing and residential homes in geographically-focused areas. It covers six homes with a combined bed total of 281..

The service provides proactive and responsive care, better supporting this vulnerable group in the following areas: promoting self-management where appropriate, optimising primary and secondary prevention interventions to avoid acute exacerbations where there is evidence to support this, and ensuring residents are treated symptomatically to maintain wellbeing. Along with undertaking detailed medication reviews which will help to reduce admissions and aid the seamless transfer of care between care settings.

Through planned and focused attendance at each care home by the ‘team’, a systematic approach to identifying residents who are at end of life will be developed, leading to appropriate support and care being implemented at the earliest opportunity. In addition, improved collaboration with older people’s mental health services will be encouraged to better support residents with dementia and other mental health conditions.


The project is in an early stage of service delivery but  many benefits have already been realised by having the service in place, including:

  • Improved medicines management
  • Decrease in number of medications being prescribed
  • Decrease in medication spend
  • Improving transfer of medicines between primary and secondary care
  • Undertaking timely follow up of patients
  • Decrease in GP visits to care homes
  • Increase in education and learning within the home from careworkers

Early indication (after three months) has shown significant improvements in prescribing practice, and an increase in the prevalence of comprehensive care plans and treatment escalation plans. Patients, families and care home staff are all highly engaged and are highly satisfied with the service. We hope that in time we can develop a sense of responsibility and ownership that will result in reduced falls and unplanned admissions.

Tips for adoption

Working at scale has made this service possible. Partnership working and sharing resources and skills is essential for success. This has been evident between Livewell South West and Beacon Medical Group across a number of projects.

Dr Adam Morris, Medical Director, Livewell Southwest said: “We know that care home residents are some of our most vulnerable patients and are particularly susceptible to side effects from complex prescribing regimes. We also know that care home medical cover can be reactive rather than proactive and that many residents are admitted to acute trusts due to medication problems. This proactive multi-professional approach helps minimise avoidable harm for these patients”

For more information please contact:

Daniel Vincent
Practice Manager
Ryalls Park Medical Centre
Marsh Lane
BA21 3BA

Tel:  01935 434000
Fax: 01935 473531
Twitter:  @somersetpm