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The nurse practitioner
As a nurse practitioner , Julia di Castiglione looks after nursing and residential care homes within the CCT , alongside nurse practitioner colleagues Becky Young , Sarah Wescome and Lorrae Aldaghma . She says her work has ‘ dramatically changed ’ since she started seven years ago , before the model was established .
‘ There is whole-team support , which I didn ’ t have before . There is always somebody to speak to and support me ; between us we have created a strong set-up .’
Now working part time , Ms di Castiglione says the team is there to support and cover each other . She adds : ‘ We ’ re picking things up that much more quickly . It ’ s stopping people going to hospital unnecessarily .’
The mental health nurse
Tracey Glen-Travers , mental health nurse practitioner at Frome Medical Practice , works with two other mental health practitioners at the practice and alongside the CCT , arranging dementia and mental health reviews , helping with discharge summaries , care plans and anticipatory care .
She says working with colleagues such as health connectors , nurse practitioners and GPs has been helpful , particularly when many patients held back on seeking help during the pandemic .
Now , she says , the cost-of-living crisis is proving particularly hard for her patients , citing the case of an elderly man who cancelled his Lifeline subscription because he couldn ’ t afford it , despite being prone to falls .
‘ That ’ s where the CCT and health connectors are very creative in terms of trying to support you ,’ says Ms Glen-Travers .
She adds : ‘ You ’ re given a job to do with minimal restrictions placed on you and you ’ ve got the freedom to think about it in the team . I think that makes for a healthy work environment and a positive experience for the patient .’
The discharge liaison nurses
With the Government and the NHS focused on speeding up hospital discharge , Somerset is already demonstrating the impact of effective communication between secondary and primary care teams on reducing lengths of stay .
Clare Vause and Susannah Bruce are discharge liaison nurses at the Royal United Hospital in Bath , working on behalf of Somerset ICB to support the CCTs . Their role is to identify patients with complex health or social care needs , arrange safe discharge planning and alert the CCTs if additional support will be required in the community . This planning and communication helps reduce readmissions .
‘ It feels much more integrated ,’ Ms Bruce says . ‘ We are lucky to have information from CCTs : all that collateral and history is really helpful .’
And it works both ways : ‘ We get a flag from the CCT if they ’ re worried about someone ,’ she says , adding : ‘ Those details that you might not know – home and social circumstances – it ’ s really helpful for our therapist and doctors .’
Back row ( from left ): Jo Trickett , complex care team lead and nurse practitioner ; Jo Plenty , care co-ordinator ; Dr Dan Cook , GP ; Becky Young and Julia di Castiglione , nurse practioners ; Andre Pilling , paramedic Front row ( from left ): Emma Poole , care co-ordinator ; Dr Helen Kingston , GP and senior partner , and founder of the Compassionate Frome Project ; Sarah Wescome and Lorrae Aldaghma , nurse practitioners
The paramedic
Advanced paramedic practitioner Andre Pilling joined the CCT at Frome Medical Practice more than a year ago and supports the team by doing home visits for housebound patients identified by the CCT as having ongoing complex physical and or mental health care needs . He also assists with acute same-day presentations at Frome Medical Centre .
‘ My role is to do telephone triage and urgent visits where appropriate ,’ Mr Pilling explains . ‘ I do a lot of post-falls , risk assessments – sometimes I help with picking a patient up from the floor after a fall .
‘ The role involves collaboration with other health and social care multidisciplinary teams serving Frome Medical Centre , such as Rapid response , district nurses and the local hospice .
‘ Patient feedback is positive . They like the fact that they ’ re seeing the same clinicians all the time due to our dedicated team .’
The benefits of working together
Ms Trickett recognises the value that a close working team with a problemsolving approach can bring to providing patient-centred care for vulnerable people who need it most .
She says : ‘ The integrated complex care model was developed to connect and support patients and their families or carers with complex health and social care needs . Not only does it provide holistic wraparound care to patients and reduce admissions , but its collaborative nature has also enhanced the working lives of the multidisciplinary professionals who work within this model .’