Community services in care homes

Case study: Julie Clennell, Director of Nursing, Allied Health Professionals and Quality – Locala Community Partnerships.

Background to learning

Locala as a social enterprise and community provider of NHS funded healthcare across Kirklees, Calderdale and Bradford, works closely with GPs, social services, other local NHS organisations and local authorities to deliver a coordinated approach to care and support.  As health and care systems prepared to respond to an escalating pandemic, nurses at Locala built on these partnerships to rapidly develop new service provision to support patients in community settings.

Learning and advice to be shared

Nursing teams have been at the heart of cross-organisational partnerships which have enabled three new services to be established rapidly as part of the system-wide response.

  • The Care Home Support Service and Care Home Urgent Response model (clinical care delivered within 2 hours of identified need) were developed and put in place within a few weeks of the national guidance to prioritise community services in March 2020. The service is multi-disciplinary, with advanced clinical practitioners in nursing, therapy and care supporting proactive work around advanced care planning as well as an urgent care response within 2 hours.  In conjunction with primary care, the team was also instrumental in setting up the arrangements for regular Multi-Disciplinary Team meetings ensuring additional support for those identified as being at risk of admission to hospital.
  • The CoHoRT team (Community Home Visiting for Covid symptomatic patients) service was developed with clinical commissioning group and primary care colleagues and is delivered jointly with the support of Locala advanced clinical practitioners and primary care staff. The service provides an excellent example of partnership working at pace with shared facilities and staffing.  Locala nurses worked together across practices to ensure vulnerable patients, unable to attend a GP practice, were assessed and treated in a timely manner, thereby helping to reduce the risk of transmission in the wider community.
  • In addition, the Locala nursing team has shared infection prevention and control expertise by providing training for a number of care homes in Kirklees.

Would it be beneficial to retain these changes?

System partners are already considering the potential for elements of the new services to remain in place for the long term as they have proven initially successful and beneficial to the Kirklees system.

Each of the service innovations have helped to streamline patient care through collaborative working across primary, secondary and community care as well as social care.  It has been agreed that this has ensured a rapid response to any identified need, through a single pathway, with all the relevant partners involved.  This has reduced multiple handovers of care and addressed potential risks such as missed opportunities or potential gaps in care.

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