Multi-disciplinary support for frail and vulnerable care home residents during the pandemic

Case study: Judith A Wild, Deputy Chief Nurse and Head of Service, Continuing Health Care at Wakefield Clinical Commissioning Group (CCG)

Background of change and intervention

COVID-19 continues to present challenges in supporting people in the community and those leaving hospitals with their continuing healthcare needs. Adapting approaches to care for those at risk in our communities while reducing the spread of the COVID-19 virus has needed nursing and midwifery teams to work in different ways. These new ways of working have also offered opportunities to develop a more collaborative approach across CCG’s and independent care home providers which will be explored within this case study.

Learning and advice to be shared

At Wakefield CCG, nursing leads recognised the need to enhance its in-reach services caring for frail and vulnerable care home residents and supporting the care home staff caring for them. A Multi-disciplinary Team (MDT) model was agreed in principle to deliver the Enhanced Health in Care Homes service requirements, including the development of personalised care and support plans. This MDT model, delivered via established Personal Integrated Care Teams facilitates clinical triage of residents and urgent response to their care needs:

  • Community therapy and rehabilitation of care home residents via physiotherapists, occupational therapists and dietitians as well as support staff to ensure services are ‘wrapped-around’ the residents they care for.
  • A pharmacy support team was quickly established, including two pharmacists and two technicians, to support the step-down care of COVID-19 positive residents and those with complex care needs.
  • E-consultations offering direct access to community geriatrician and general practice services have been established to reduce delays in access to specialist care and to ensure residents can stay in their own homes, shielding where appropriate.
  • End of life care training and a ‘Gold Line’ established to support direct access to specialist advice and expertise for care home staff.
  • Advanced clinical practitioners offering additional support to residents who have tested positive for COVID-19 in the community to ensure any on-going non-acute symptoms are managed in line with best practice in their own homes.

Furthermore, new ways of working are being embedded:

  • Named clinical leads aligned to a Primary Care Network and practices ensured collaborative working and supports weekly reviews with primary care colleagues.
  • Ongoing support via the Virtual Care Home Team comprising of experienced nursing staff who support with training and act as a virtual ‘wobble rooms’ for care home staff who may have been affected by the pandemic.
  • Daily check-in support calls from the CCG nursing teams to offer additional support and support completing of the Capacity Tracker.
  • Access to psychological support associated with the COVID-19 response including bereavement support.
  • Collaboration around infection prevention and control training has supported the purchase of equipment to enable remote observations.

Would it be beneficial to retain these changes?

Residents have continued to receive high quality care within their own homes and staff have benefited from additional education, training and support.

Good relationships were already in place and this joint working further aligned leadership across the health and social care system during this challenging time, as well as supporting new improved ways of working for staff across different settings.

Those approached continue to support shared professional decision-making within the community and have supported the establishment of fully representative Independent Sector Liaison Groups – driving collaboration and sharing of experience, knowledge and skills. Coproduction of the approach has shown many benefits and continues to support local leadership pipelines to facilitate  cross-sector collaboration and joint working. This is already enabling consideration of a dedicated 24-hour telehealth/local care homes support offer and a Care Homes Falls Responder pilot is in development with the local Trust and care homes to ensure shared professional decision-making from the outset.

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