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  • Issue

    Spread across the largest geographical area in the UK, Northumberland’s elderly population is higher than the UK average.  8.8% of the population is aged over 75 compared to a UK average of 7.7%, and the trend is to rise. With an ageing population comes greater pressure on health and care resources. Acute hospital beds were being routinely used for frailness and long-term illnesses.  This impacted upon the availability of beds for emergency and elective care, as well as budget.

    Solution

    Northumbria Healthcare NHS Foundation Trust entered into a formal partnership with Northumberland County Council which was responsible for social care across Northumberland.  This new partnership helped foster closer working relationships between health and social care professionals, and a more joined up and collaborative approach led to a more efficient, higher quality model of care.  Northumbria now has a comprehensive elderly care strategy in place to keep the elderly well supported and safe in their own home for as long as possible.  The elderly services that have been developed include, not exhaustively:

    • Specialist geriatricians and nurses
    • Rapid response is provided by skilled nurse practitioners and pharmacists offering advice and urgent care support for patients nearing the end of life to prevent unnecessary hospital admissions;
    • Empowering patients to self-manage chronic diseases supported by specialist nurses and telecare;
    • Urgent Response Service to provide emergency care, equipment and adaptations for patients to live safely at home,;
    • Integrated complex case management
    • Coordinated multi-disciplinary services designed to prevent unnecessary hospital admissions and to facilitate safe and fast discharge;
    • Specialist health and social care access through a single point of access called onecall operating 24 x7;
    • Dementia strategy and plan
    • Utilising the latest technology and digital health solutions, including telecare, telehealth;;
    • Integrated pharmacist reviews;
    • Frail Elderly Care Pathway Programme – multidisciplinary approach to maintaining health and independence including rapid access assessments and fall prevention;
    • Reablement and Short Term Support Service;
    • Medical Ambulatory Care to manage acute medical emergencies safely out of hospital; and
    • Elderly Care Home Service – provides specialist assessment, rehabilitation care and advice to people living in residential or nursing homes for a range of problems including difficulties in speaking, swallowing, moving and doing day to day activities.

    Outcomes

    Northumbria’s new approach has led to a reduction in:

    • Admissions to long term care;
    • Packages of care needed;
    • Emergency admissions and readmissions;
    • Emergency Department attendances;
    • Delayed discharges;
    • Length of stay in community beds; and
    • Cost

    There has also been an increase in:

    • The number of people who go directly from hospital to their normal place of residence;
    • Patients who have maintained or gained function; and
    • Patient and carer experience

     

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