A complex care team in Somerset, working in an integrated neighbourhood team model, has supported more than 21,000 people in the last two years, helping to reduce unplanned hospital visits by 14%.
They take referrals from across the system and advise on complex management, service co-ordination, care planning and ensuring gold standard communication.
A complex care team in Somerset, working across three primary care networks (PCNs) in Somerset Integrated Care System (ICS).
Three teams, working across three PCNs, take referrals from across the system and co-ordinate their care in a joined-up way, ensuring gold standard communication.
They have supported more than 21,000 people in the last two years, reducing unplanned hospital visits by 14% (compared to pre-covid data).
The aim / need
They wanted to:
- establish central care co-ordination for patients in South Somerset
- bring together a complex care team delivering effective services for people with multiple complex conditions
- improve care for people with multiple complex conditions
- improve communication between the organisations looking after the person
- reduce fragmented care and duplication
- reduce higher cost work which is unable to fully meet the need of the person
- improve job satisfaction of those providing care.
For patients who have complex care needs, providing the holistic care they require within the community can often be challenging. Holistic care often consists of many overlapping health services such as physiological, psychological and social.
People who require extra support to maintain their health and wellbeing are often in need of a more comprehensive review than their local GP can provide. Multi-disciplinary community team working enables the right person to look after the patient at the right time and place.
Structure and partners
The Complex Care Team (CCT) was established in 2016, pre-dating the introduction of PCNs.
Three CCTs, each aligned to a PCN, provide comprehensive assessments of complex patients who are often frail and elderly. They co-ordinate and share information with GPs, community teams, and secondary care hospital teams.
Each team is made up of an experienced GP, a senior nurse and a support key worker and was designed to support the population across up to six GP surgeries, focusing on people with the most complex needs.
This fitted with the PCN footprints, which were introduced later. (In South Somerset, neighbourhoods have a similar geographic area to PCNs.)
The teams take referrals from GPs, hospitals, carers, and other organisations and get admission and discharge data daily so they can follow people up. They also plan to use an AI tool in the future.
The GP, nurse and support worker from each team hold weekly huddles as multidisciplinary teams (MDTs) in GP surgeries.
These include care professionals from primary, secondary and community care as well as the voluntary sector and social care, incorporating the whole GP team and health coaches.
They discuss hospital admissions and discharges for the team caseload, and any of concern to the practices, community or hospital teams.
The meeting participants discuss hospital admissions and discharges for complex patients, those on the CCT caseload, and any of concern to the practices, community or hospital teams.
CCT members advise on complex management, service co-ordination, care planning and the ability to contact and visit patients and carers when appropriate.
A further weekly community MDT huddle, involving community health, social and mental health teams, as well as voluntary sector and hospital discharge teams, provides a forum to share knowledge, and enable visit/work-plans to be made without duplication.
This ensures the most appropriate team engages with the patient, linking and supporting other services. This approach has evolved organically to become a coherent neighbourhood team, encompassing all community-based teams and many hospital outreach teams.
CCT community role
The CCT has a liaison role communicating between general practice and the community MDT. There are regular MDT huddles with a Parkinson’s team and hospital care of the elderly, for advice and to ensure sound communication regarding patients under shared care.
The CCT also has active involvement with acute hospital attendances of complex patients, by providing detailed knowledge to enable safer care planning, particularly when there are safeguarding and carer-strain concerns.
Shared knowledge enables proactive and personalised management of patients’ social, health, mental health and general support needs.
This results in advanced care planning which lowers the risk of crises that require urgent care, ensuring best chances of care at home when unavoidable deteriorations occur. Teams work proactively with the person to ensure ‘what matters to them’ is discussed and actioned.
The CCT co-ordinates the response from appropriate agencies to emergency needs, supporting the patient in the correct place for them, with prior knowledge of the patient’s health, wishes and support.
Any urgent need may be identified by visiting professionals including community staff, GPs and members of the CCT themselves, or any other route.
Communication and building relationships
A pivotal role of the CCT is relationship building, peer support and communication. This is key in building the successful neighbourhood team, leading to mutual trust and respect, with a shared understanding of each other’s skills and roles.
A key motivator for this is when professionals realise that they have knowledge of the same patients but were treating them in isolation.
Also supporting this is the CCT’s access to all services’ IT systems. This provides invaluable information that reduces time spent searching for duplicated patient information.
Foundation Level 2 doctors are trained in a shared complex care and GP surgery placement for four months, which will contribute to a better understanding for the new generation of future primary and secondary care doctors.
This service also offers placement for frailty trainee advanced care practitioners, building on a holistic approach to patients with complex care and often frailty needs.
- Measuring in-depth quantitative outcome data for the service. For example, measuring efficiencies of service, or measuring ‘non-events’ can be challenging.
- Building trust amongst multi professional teams takes time.
- Resilience of team/consistency of service cover
Multidisciplinary community team working enables the right person to look after the patient at the right time and place.
The combined complex care, huddle and health coach system has been linked with a 14% reduction in hospital admissions, as part of system-wide intervention within general practice and secondary care.
Adult social care manager: “Being able to shed the usual organisational boundaries and access the skills and knowledge of the complex care GP, so we truly work together to get the best outcomes for people, me has been one of the key benefits of the role.”
Voluntary sector worker: “For patients recently diagnosed with dementia, it has helped reduce clinicians and/or support agencies visiting a patient at the same time, which confuses the patient. Well timed visits help people to come to terms with their diagnosis receiving advice when needed, rather than being bombarded by information all at once initially (which often went in the bin).”
Ingredients for creating the integrated team:
- Shared values – including person centred care
- (Compassionate) leadership by all
- Clear communicators
- Training and induction for roles, along with ongoing development opportunities.
Whole time equivalent for each to cover the whole week.
- GP with experience of managing complex needs
- Band 4 assistant practitioner/care co-ordinator
- Nurse with experience of managing complex needs.
Equipment and more
- Workspace – ideally in the community
- Ability for digital interactivity for communication
- Communication strategy
- Meaningful evaluation
- Adequate funds for ongoing development of the team (this will help to retain the people you have)
- Access to local hospital admission and discharge data.
Steps to create the core team
- Arrange a meeting of relevant “stakeholders” (including primary, secondary and community senior health, social care, voluntary care, digital colleagues etc leaders) in the neighbourhood to discuss the concept of the complex care function.
- Form core values about what matters most to the neighbourhood team in terms of what the complex care function needs, and develop what the goals of the complex care function should be.
- Work with the local acute services to ensure a process of identifying people in the neighbourhood who have been admitted to hospital or considering discharge.
- Source the equipment and infrastructure required in the ingredients.
- IT systems – consider what most practices in the neighbourhood use and have early discussions with digital colleagues to ensure systems are joined up ready for use across a range of services.
- Decide how you want to measure the value of the complex care function so that you can regularly improve what is offered along the plan-do-study-act cycle.
- Workforce – before recruiting consider not just roles and skills set but key principles of the people who will be best suited to the role and develop job adverts and job descriptions accordingly, this includes people who:
- share the core values of what you want to deliver (as defined by the stakeholder meeting)
- are team players who are committed to the purpose of the whole team, not just their own function
- are diverse (this will bring greater breadth to the team)
- work well in teams
- want to develop
- can work autonomously
- Develop job adverts and job descriptions
- Recruit only those people who are suited to the role, it is better not to recruit and have an interim gap, than recruit the wrong person.
- Create a local induction and training package for new workers onto the team, which includes becoming familiar with:
- the values and goals of the complex care function
- each other (can include team building exercises)
- the venue and the area they will be working in
- the multi-professionals they will be working with
- skills required and specific areas of training such as coaching, leading MDTs, compassionate leadership, IT skills etc
- it may also involve shadowing a neighbouring complex care team, if available.
- Go live with the complex care function when the induction is fully complete, not before.
- Consider a mini complex care function (such as in one general practice) for the first eight weeks while ensuring you have everything in place to maximise the function. If everything is going well, you may want to roll out the function earlier than eight weeks.
- Provide regular supervision for all team members.
- Grow the team over time according to the local need, while holding true to the original values.
Next steps and sustainability
From this structure other projects have been supported such as dementia reviews, looking at medications, and social prescribing projects. They also train Foundation year 2 doctors, providing valuable insight into community working to potential GPs or hospital doctors.
This has spun out into the ‘Show me your meds, please?’ project, which has evidenced benefit in medicines optimisation and waste reduction, environmental impact and earlier identification of cognitive decline. Read more about the results of this project.
Find out more
Contact Dr Deb Gompertz, Clinical Lead Complex Care South Somerset: email@example.com