Community nurses are pioneering an innovative approach to support patients with multiple long- term conditions and reduce pressure on accident and emergency departments in West and North Yorkshire.
A new complex care team has been introduced by Bradford District Care NHS Foundation Trust, Airedale NHS Foundation Trust and a range of other partner organisations.
“We are providing holistic care that is personalised to the needs of each individual”
Working across Airedale, Wharfedale and Craven the new multi-disciplinary team has reduced A&E admissions by 39% and attendances by 19% since early 2016, according those behind the pilot.
A trust spokeswoman told Nursing Times that non-elective admissions fell from 299 to 183 after the team’s introduction, while A&E attendances were reduced from 364 to 295.
Led by Helen Cowley, who has a background in community psychiatric nursing, the team brings together a range of skills and professions covering physical and mental health, and social care.
As well as the two trusts, it also includes members from local GP federation Yordales Health, the charity Age UK, Carers Resource, and Bradford and North Yorkshire councils.
The team comprises a community psychiatric nurse, community nurse, advanced nurse practitioner, occupational therapist, psychologist, physiotherapist, rehabilitation consultant, physical therapy assistant, dietician and GPs.
In addition, personal and carer support “navigators” from local voluntary organisations work with patients to provide advocacy services and help connect them with activities to reduce social isolation.
Referrals are patients that have multiple long-term health conditions and are highly dependent on health and care services, are frequent users of A&E and may also have psychological or social needs.
The service focuses on 3% of the local population (3,900 people) that utilises 39% of primary and secondary health care, and costs around £29m at a local level annually, said the Bradford trust.
“We’re really excited about this new way of working”
As well as a reduction in A&E contacts since the team was introduced, patients have also become less reliant on other intensive high cost services including long-term care, said the trust.
It added that the team built individuals’ confidence and knowledge to manage their own care and live more independent and healthier lives, and improve their general quality of life.
James Cooke, district nursing service manager at Bradford District Care, said: “Working with all our partners, we are providing holistic care that is personalised to the needs of each individual.
“This ensures that care is planned, co-ordinated, proactive and regularly reviewed by the complex care team,” he said. “We all have shared outcomes and a close integrated working relationship.
“Our aim is to support those with complex care needs to improve their wellbeing so they can look after their own health, by giving them advice and building their confidence and skills, so they can make informed decisions about their care,” said Mr Cooke.
“All the partners involved have shared information and knowledge about people who are using the services, providing we have their permission, to ensure a co-ordinated and holistic approach,” he said.
Cath Gregson, head of therapy and rehabilitation at Airedale, said: “We’re really excited about this new way of working and the positive impact that it has had on people’s lives.”