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CCG rolling out nurse co-ordinator role to better integrate care

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South West Lincolnshire Clinical Commissioning Group has committed to fully rolling out a new practice care co-ordinator role, held by senior nurses, across its area.

There are currently 16 practice care co-ordinators employed across the CCG area, which are now planned to increase to 19 – providing one post in each of the GP practices within the CCG area.

“I am the link nurse between primary and secondary care so patients have continuity of care”

Elizabeth Reader

The highly qualified nurses’ primary role is to support people with complex needs and enable them to remain in their own home, by working closely with other local health and social care providers.

As part of Lincolnshire’s “neighbourhood team” approach, they develop support plans to reduce unplanned admissions, support discharge and act as a key contact for providing the patient’s care.

The co-ordinators have regular contact with their patients, visiting them in their own home and are able to provide longer appointment times, said the CCG.

They also undertake joint visits with other providers of health and care services, ensuring the patient only has to tell their story once.

The role plays an integral part of the CCG’s neighbourhood team programme that provides more integrated support for patients requiring support from health and care organisations.

It noted that the approach, which has its origins locally in 2013, was intended to ensure that the patient and their family or carer were at the “centre of any decision being made about their care”.

“We have been able to get proactively involved, signposting patients to services”

David Baker

Three neighbourhood teams – Sleaford, Grantham Town and Grantham Rural – are being developed to integrate care for patients registered with a GP practice across South West Lincolnshire CCG.

The programme is run jointly by South West Lincolnshire CCG, Lincolnshire Community Health Services, Lincolnshire Partnership Foundation Trust and Lincolnshire County Council.

The neighbourhood teams bring together local health and social care professionals – including community nurses, GPs, social workers, community psychiatric nurses and therapists – from different specialities into a single patient-focused team.

Patients are given “more personalised care than ever before, helping them to live independently, live longer and enjoy better and more fulfilled lives”, said the CCG.

Elizabeth Reader, practice care co-ordinator for St Peter’s Hill Surgery in Grantham, said: “I work with the most vulnerable people in their own homes/care homes to monitor and liaise with multi-disciplinary teams to keep them safe and well as able.

“My aim is to keep people in their own environment for as long as possible,” she said. “I am the link nurse between primary and secondary care so patients have continuity of care.

“I am also their named nurse so they feel supported and reassured, I can be contacted at the surgery during normal working hours,” she added.

Dr David Baker, a GP at Vine Street Surgery in Grantham, said: “Previously, we were only able to treat those patients with complex needs for their medical conditions, however we were aware that they had other needs.

“In many cases, patients were either living alone, had no support or they needed to be admitted into hospital, but were reluctant to go,” he said.

“By introducing the practice care co-ordinator role we have been able to get proactively involved, signposting patients to services and putting care packages together jointly, with input from the patient,” he said.

A spokesman for the CCG told Nursing Times that role had been in place since April 2015.

“The idea was developed with our practices, to ensure the role would be a key member of the GP practice team, as well as link to the other partner organisations involved in the Neighbourhood Teams,” he said.

“The practices that don’t have a role in place are currently going through the recruitment process as they have seen how the other practices have benefitted from the role,” said the spokesman.

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