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Your Healthcare plays key role in new community service

A new way to support patients with multiple long-term conditions and frailty who are at risk of becoming reliant on emergency care, has been launched in Kingston, with Your Healthcare as a key founding partner.

Proactive Anticipatory Care, or PAC, has been developed with health and care partners in health, social care and the voluntary sector, to provide patients with joined up care that helps them to stay out of hospital and have a better quality of life. It helps patients stay healthier and more independent and addresses the full range of social, economic and environmental factors that influence a person’s health and well-being, and any inequalities they may experience.

A new role of care co-ordinator has been created to make sure patients included on the PAC programme have access to a wide range of services across health and social care. This will include GPs, community nursing teams, social workers and mental health workers, and other experts when needed, which could include therapists, cardiorespiratory teams, dementia care teams and hospital doctors. Care co-ordinators will ensure meetings take place that include all the professionals involved (multi-disciplinary meetings or MDTs) and that actions are followed up. They will be responsible for overseeing all health needs and crucially, will also offer support on issues such as social isolation.

Grant Henderson, board lead for frontline services, and Ali Child, frontline service lead (integrated services), took part in the launch event, making a presentation to health and social care teams from across the borough.

Grant commented: “While co-ordinated community care is obviously not a new thing in Kingston, developing the dedicated role of care co-ordinator has been shown to improve communication and strengthen relationships between different professionals, resulting in better care for patients and fewer GP attendances.”

Ali added: “An aspect of PAC that has had real impact during the pilot phase has been the opportunity to look at patients’ situations holistically, which includes looking at the needs of informal carers – often family members. As an example, we were recently able to support the daughter of one of our patients to start an anxiety management course, find the right financial support and access benefits advice. The positive impact on her mother, the patient, was significant.”

Working across two Primary Care Networks in Kingston and Richmond, a PAC pilot launched in May 2021, with GPs referring suitable patients into the pilot. Patient feedback was crucial in the development of the service. Results for the pilot showed a significant reduction in unplanned care attendances for those involved in the project for more than four months.