20 | Nursing in Practice | Spring 2023
TEAMWORK
Communication and collaboration
in a complex care team
What ’ s great about multidisciplinary teamworking ? Nursing in Practice finds out from several members of a team supporting patients with complex care needs in Somerset
Nurses are among those working in three closely coordinated and responsive complex care teams ( CCTs ) in primary care networks in Somerset . The model began in Frome Medical Centre PCN , before Central and West Mendip PCNs adapted it to their needs .
The CCTs help patients manage their health and social care needs and live as independently as possible , which includes supporting families and carers . They do this in partnership with providers such as GPs , district nurses , mental health specialists , adult social services , occupational services and local hospitals .
This integrated model is delivered to patients with comorbidities , palliative care needs or other vulnerabilities , and those who need longer-term support after hospital discharge .
Based on a compassionate care model , it has achieved a 14 % reduction in hospital admissions ( against a 28 % rise across Somerset ) and a 21 % fall in healthcare costs – which the team says is a welcome by-product of working together for patients .
A vital factor has been three nurse CCT team leads collaborating to share best practice : Johanna Trickett , nurse practitioner ( NP ) at Frome Medical Centre ; Jacqui Cross , nurse at CCT West Mendip ; and Sarah Stone , NP in Central Mendip .
Mrs Trickett , who won the General Practice Nurse Leadership Award at the South West General Practice Nurse Leadership Award last year , puts the service ’ s ongoing success down to communication and being empowered to share and act on good ideas .
Ms Cross cites the idea to hold regular frailty meetings managed by the CCT , involving secondary care consultants and the wider multidisciplinary team . Patients are reviewed holistically and referrals and actions are managed locally in a timely manner , helping to reduce admissions and stress on secondary care .
Ms Stone recalls a vulnerable patient waiting to go into a care home , whose family and carers were struggling . ‘ I arranged a meeting at the patient ’ s home with all the health professionals involved .’ A plan of action was agreed and the patient was in a care home within four days . The patient and her family were at the forefront of the meeting and were very happy with the outcome .
The GP
Dr Helen Kingston , a senior GP partner at Frome Medical Practice , was behind the development of a system that has allowed a practice with 30,000 patients to provide holistic care and boost job satisfaction for staff .
‘ Somerset gave us that devolved leadership and allowed us to develop , from the ground up , the services that we felt we needed ,’ says Dr Kingston .
‘ We ’ re a big team with lots of people specialising in different areas but , probably more than a small practice , we had issues with continuity and size . ‘ As a GP , you recognise how much relationships matter , how important continuity is , particularly for that risky cohort who are frail , vulnerable , and may have mental health problems or difficult life circumstances . Knowing the backstory really helps ensure you ’ re doing what matters most to that individual .’
As a result , Dr Kingston built a system within the practice to embed communication between separate services , so patients did not have to repeat their story . This began with multidisciplinary meetings to identify and discuss patients who might be ‘ falling through the net ’ and require additional support .
When patients discussed problems that might indirectly affect their health but were outside her scope as a GP , she could signpost them to resources or refer them directly to health connectors . From this , a practice complex care hub was developed , a model that has gained international attention . It has subsequently been adopted and adapted in Central Mendip PCN , and West Mendip PCN is looking to expand the model even further .
The system was designed to empower healthcare professionals to take ownership of problems rather than sitting rigidly within their job role , Dr Kingston explains . Developing relationships with other allied professionals , district nurses and community services has allowed gaps between services be identified .
‘ That is really important for retention , recruitment and feeling you ’ ve done a good job when you go home at the end of the day ,’ she says . She acknowledges , though , that there is always more that could be done .
‘ Austerity is not helping people , there is a lot of uncertainty in people ’ s lives ,’ she points out . ‘ The funding of social care is a difficulty , and we continue , like every practice , to have difficulty recruiting and retaining staff because of workforce issues . But we ’ re really lucky to be supported in developing this model and by the ICS to continue moving forward to deliver it .’
PICTURE CREDIT