Hear nursing, midwifery and care staff talk about their experiences of identifying unwarranted variation and taking a lead in making the changes necessary to deliver improved outcomes, better experience and better use of resources.
- Nottingham CityCare Partnership – The Holistic Worker model
- Leeds Respiratory Network
- The Hot Potato Project – Kendal, Cumbria
- East Coast Community Healthcare – Prevention and management of skin tears in residential homes
- NHS RightCare Long Term Condition Scenarios: Betty’s story, wound care
Nottingham CityCare Partnership is a social enterprise delivering community healthcare in Nottingham. A need for change was identified within Adult Services Urgent Care team in response to necessity. The holistic worker model of integrated working was initially commissioned as a pilot to urgently 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 to older people with long term conditions, avoid unnecessary admissions to hospital or care homes and provide tangible social benefits. Prior to the model being developed, different teams worked in a very individual way, despite being a multi-disciplinary team. Each patient would have 4 separate assessments by a nurse, physiotherapist, occupational therapist and social worker, and they would need to keep repeating their story.
Each member of the team is now trained in each other’s disciplines up to the level of ‘general assistant practitioner’ and this enables one team member to carry out a wide range of practice help and assistance during a visit to a patient’s home. If more specialist intervention is required the individual can make a referral to other colleagues in the team as appropriate.
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. Patient satisfaction remains high and was over 95% at the time of filming; the number of inter-team referrals has reduced significantly and a patient has fewer visits with better outcomes and experience.
From analysing data identified through the NHS Atlas of Variation it became apparent that Leeds had unwarranted variation with regards to respiratory care and outcomes, especially within primary care. To address this inequality two practice nurses established the Leeds Respiratory Network and developed a specific education approach for health care professionals.
Free educational meetings were organised, and social media accounts set up, which are used to keep professionals updated as new guidance and resources become available. The information shared helps improve the quality of care that patients receive.
The practice nurses are now working with a collaboration of 8 GP practices in Leeds to help standardise respiratory care and reduce unwarranted variation. Baseline data has been collected and an evaluation will be undertaken in a year to quantify the impact their work has had but early feedback is very positive as to improved outcomes, experience and use of resources.
In Cumbria challenges to access mental health support services had been identified and a longer wait period compared to other similar services within the country. To support members of a local youth theatre group understand more about mental health issues, a student nurse developed “The Hot Potato Project” and with support from the local Child and Adult Mental Health Service (CAHMS) created workshops where the young people could express their fears and anxieties regarding mental health and wellbeing whilst in a safe and secure peer environment.
A DVD of 40 monologues was produced, which is now being used as an educational tool amongst the schools in Cumbria, educating both the young people but also the health professionals such as school nurses who are using it. It has also been used in a university for pre-registration students when discussing holistic care.
The project focuses on developing emotional resilience within young people, therefore improving their overall mental wellbeing. The culture created by the project is one where mental wellbeing is discussed openly; promoting the young people’s health as it ensures they seek help with mental illness if needed and are able to identify signs when requiring help or intervention.
There is evidence that early intervention and prevention is particularly important in affecting outcomes for children and young people and can have a significant positive impact on a person’s prognosis. Within Kendal there has been a very positive increase in young people accessing support at an early stage when they find that they are struggling to talk about mental health.
The Tissue Viability team of East Coast Community Healthcare provides tissue viability advice and support for the prevention and management of pressure ulcers, skin tear, and education across Norfolk and Waveney. The team identified unwarranted variation with a high level of requests for same day visits for residents in care homes with reported skin tears; leading to increased demand on the district nursing service. Additionally it was often discovered that a skin tear had not occurred and there was a frequent use of inappropriate dressings or inappropriate referral to hospital. The district nursing team discussed these issues with the Tissue Viability team, and agreed a need to improve the recognition and prevention of skin tear in relevant care homes as a catalyst for the change of practice.
Evidence and research on skin tears was reviewed and a training package and a pathway for their care was developed; ensuring safety was central and a clear referral process to other services when necessary. Three care homes were identified to pilot the skin tear pathway for a 3 month period; including a review of the pathway and training package.
The care of 26 residents was audited and the outcomes identified successful application of the correct wound care dressings, completed healing rates, and a decrease in the number of same day visits requested inappropriately. The education package and treatment pathway is now being rolled out to other care homes and district nursing teams in Great Yarmouth and Waveney, including Health Care Assistants and Assistant Practitioners who provide care to patients at home. There has also been a request from a neighbouring Clinical Commissioning Group for a similar programme.
Betty’s story provides an example of what an ideal wound care pathway looks like, particularly in primary and community nursing. It demonstrates how nursing and care staff can use the Leading Change, Adding Value framework to identify and address unwarranted variation in wound care. This resource been produced in conjunction with the RightCare programme team.
Further Leading Change, Adding Value video case studies
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