ACUTE VISITING TEAM
Community Practitioner Alliance CIC are working with North Halifax Primary Care Network to provide a team of Acute First Contact Paramedics.
This is in line with the latest government strategy to introduce new and diverse roles into primary care, which will enhance access to timely medical assessment and provide a range of new skills.
The team of Paramedics are all highly trained in advanced physical assessment, minor illness and minor injuries and are predominantly used to provide home visits to our housebound patients.
The team has a fleet of fully equipped vehicles and are able to provide care in a timely fashion which will enable more patients to be treated in the community and avoid unnecessary hospital admission.
The GPs will assess patients as suitable for the service and will arrange the visit for the same day ensuring a timely response to acute medical problems.
The Paramedics have the full support of the GPs if they require any specialist advice or to arrange further investigations or follow up appointments. The team has been operating for a number of months and the feedback from this innovative service to date has been extremely positive.
Michelle – Ageing Well Practitioner
Our Ageing Well Practitioner is here to help people who are living with frailty. They will assess needs and design a plan to ensure that the right support is given to help live as well as possible.
The Ageing Well Service in North Halifax Primary Care Network has been continuously developing over the last 2 years. The aim of the role is to take a proactive approach to providing person centred care, helping patients to age well within their own home.
With a population size of approximately 7000 people over the age of 65 years this took some careful consideration, but after a review of the data, existing services, and the needs of this group of people our ageing well nurse was able to identify gaps in service and develop a model of care to address these needs in a holistic way. Patients with rising risks have been identified early through the data or via Clinician referrals and then offered a holistic assessment of needs and development of a personalised care and support plan. Staff have undertaken frailty training to help recognise and support problems early and multi-disciplinary team meetings have been set up occurring on a weekly basis with the wider health and social care team present to look at more complex cases and management plans.
The ageing well nurse predominantly completes home visits completing a holistic assessment of patient needs. Exploring the patient’s ability to managing their activities of daily living, medication management, nutritional intake and risk of malnutrition, ability to manage their health conditions, clinical observations, and social support needs. Look at what matters most to the patient and what is preventing them meeting their goals. Additional skills include assessment and management for minor illnesses, wound care, completing a basic medication review, advanced care planning discussions and DNACPR forms, assessing and ordering equipment, Carer support, lifestyle advise, signposting and referrals to other services such as social care, falls team, district nurses.
Other PCN teams involved in supporting the ageing well work include the social prescribing link workers, care co-ordinators, occupational therapist, and clinical pharmacy team.
We hope that this support will improve patient care and reduce GP visits and appointments, reduce hospital admissions and length of stay. We aim to reduce falls and improve prescribing of medications.
Review of support provided to date has shown patients feel more activated in managing their own health and wellbeing and we have seen a reduction in GP contacts and community service contacts.
Patient feedback has included:
“you brought out a little bit of the old spark in me”
“you offered me help when I was at my worst and I’ll never forget that. The service was caring and understanding – tell your boss it’s a 10/10 from me. Thankyou for getting me to a better place”
“at first I thought why do I need this. Good to know there is someone you can contact especially when there are a lot of barriers to accessing GPs”
If you feel you are someone or know someone that would benefit from an assessment by the ageing well team then please contact the GP surgery. Triaging will then take place and if appropriate a visit arranged.
Our Clinical Pharmacist (CP) team came into being in August 2020 when 4 CP started working for the Network. Meet the team:
Muddasser – Lead Clinical Pharmacist
Tahir – Senior Clinical Pharmacist
Zaine – Senior Clinical Pharmacist
Mehnaz – Clinical Pharmacist
Shazia – Clinical Pharmacist
Umayr – Clinical Pharmacist
The role of Clinical Pharmacists was introduced by NHS England with the aim of pharmacists taking a lead in medicines optimization. Medicines optimization is about ensuring the right patients get the right choice of medicines at the right time. This is a person-centered approach that improves safety, adherence to treatment, and reduces waste.
Main work streams for the team are:
Daily prescription queries
Structured Medication Reviews
Care Home prescribing
Reconciliation of hospital discharge summaries
Seasonal vaccination programs for care homes
The Clinical Pharmacists also manage long-term health conditions by carrying out:
Hypertension management clinics
Diabetes medication optimization clinics
Lipid optimization clinics
Any new medicines optimization projects
One key area of the contract is Conducting Structured Medication Reviews (SMRs) which is a comprehensive, holistic, patient-centered review that aims to support people with long-term conditions or who take multiple medicines, especially the elderly and people in care homes, to optimize their medication by improving health outcomes.
The Pharmacy team leads in developing relationships with members of the MDT to support integration of the pharmacy team across health and social care, including primary care, community pharmacy, secondary care, and mental health, by also working in partnership with commissioners, social prescribers, and local voluntary, community and social enterprise (VCSE) organizations and community groups. As part of the NHS agenda for Enhanced Healthcare in Care Homes, our Clinical Pharmacists are part of the MDT Team which engages in the care home ward rounds.
FIRST CONTACT PHYSIOTHERAPY
Our First Contact Physiotherapy service was launched in February 2020.
Meet our First contact Practitioners (FCP) in physiotherapy:
Rosie, Mags, Tom
Together they offer in excess of 80 hours of physio assessments per week.
FCP in physiotherapy receive referrals by our partner practices and from within the PCN team and assess and diagnose musculoskeletal issues. They provide the first point of contact whereby those who visit a GP for a musculoskeletal (MSK) problem will instead have an appointment with an FCP physiotherapist.
The opportunity to gain access to immediate specialist physio assessment is very well received by patients. It saves time for the patient (no more waiting for an appointment at the hospital) and GP surgeries (fewer GP appointments are required as reception staff can book patients directly with the FCP). Treatment/diagnostics can be administered more quickly and recovery is expedited. FCPs are highly qualified and experienced and able to assess, diagnose, offer treatment advice, and manage patients with MSK issues.
BENEFITS FOR PATIENTS IN THE NORTH HALIFAX PCN
Quick access to expert musculoskeletal assessment, diagnosis, treatment, and advice.
High satisfaction and patient experience ratings.
Shorter waiting times and fewer appointments than traditional secondary care referral.
Simpler logistics, reducing the need to travel, potentially avoiding missed appointments or suffering administrative errors.
Opportunity to get lifestyle and physical activity advice from a qualified professional.
Longer and more thorough appointments than GPs can currently offer.
More in-depth appointments mean patients feel listened to, cared for, and reassured.
Short-term problems are treated faster, preventing them from becoming chronic.
Opportunity for those with chronic conditions to get a good understanding of their condition and the exercises and lifestyle changes that will help improve it.
Quicker access to diagnostic imaging if clinically appropriate.
In addition to routine physio assessments, Mags and Rosie offer joint steroid injection therapy every month in practice setting, therefore reducing the waiting time for treatment by secondary care.
Meet our Mental Health Wellbeing Practitioner – Howard and Claire
A mental health wellbeing practitioner plays a crucial role in supporting individuals’ emotional and psychological well-being. They work closely with clients to provide guidance, coping strategies, and tools for managing various mental health challenges. These practitioners offer a safe and non-judgmental space for individuals to discuss their concerns and feelings. They may conduct assessments to determine the best course of action, provide psychoeducation to increase awareness about mental health, and offer evidence-based interventions such as mindfulness techniques, relaxation exercises, and stress management strategies. By fostering open dialogue and empowering individuals to develop resilience and self-care practices, mental health wellbeing practitioners contribute significantly to enhancing overall mental and emotional wellness.
Meet our Nursing Associate Jade.
She is highly trained and carries out assessments on most some of the vulnerable patients, i.e. those with learning disabilities and those residing in care homes.
PERSONALISED CARE TEAM
Consists of Care Coordinators, Health and Wellbeing, Mental Health and Social Prescribing.
Meet our team of Care Coordinators:
Lauren, Alison, Natalie and Katia
Working behind the scenes and providing the invisible link between the surgery, other services, and care homes, making care quick and efficient.
The role of a Care Coordinator for North Halifax Primary Care Network (PCN) is to help support the PCN to deliver the Enhanced Health in Care Homes Framework by being the link between PCN, surgeries and care homes. This work involves coordination of weekly rounds, monthly multidisciplinary meetings (MDT) and on demand communication with the care homes. Our EHCH care coordinators play a vital part in coordination and execution of seasonal vaccination campaigns for residents.
They coordinate the delivery of:
– Ageing Well Project for over 65 years olds
– Learning disabilities annual reviews
– Cancer care reviews
– Multidisciplinary team meetings in Safeguarding and Palliative care
– Long-term conditions review for housebound patients
– Other care related project work
– Covid vaccination campaigns
– Scheduled work by clinical pharmacists
– PCN clinics – physio, podiatry
Care Coordinators help promote cancer screening and education to support the delivery in the Early Cancer Diagnosis work. To do this, the Care Coordinators plan and deliver promotional events for staff, patients, and the wider area to promote cancer screening programmes.
Health and Wellbeing Coaching
Meet our Health and Wellbeing coach (HWBC) – Laurence
If you have a Long-Term Health Condition and are interested in improving your health you can speak to our Health and Wellbeing Coach.
Many issues can be discussed including how to increase energy levels and reduce fatigue, live well with pain and breathing difficulties, healthy eating, relaxation and social contact.
Gradual changes toward a healthier life can slow the progress of a long-term health condition.
The Health and Wellbeing Coach is there to have an unhurried conversation with you about what is important in your life. For example, being able to go for short walks might mean you are able to spend more quality time with the people you love. Did you know that social contact and staying as active as you can are clearly shown to significantly slow the progress of a long-term condition?
You may have a condition which affects your sleep and leaves you feeling tired a lot during the day, maybe you have diabetes or COPD together. It is common to have more than one long term condition. The Coach understands that living daily with these conditions can feel overwhelming and isolating. You may have been thinking for a while about making healthy changes but feel unsure about how to start or that you need more confidence. Health and Wellbeing Coaching can help you to improve your confidence and find your motivation. Small wins are celebrated and seen as valuable. Patients say they can see their inner strengths they had forgotten that they had. The coach will work together without judgement through difficulties on the path toward making and maintaining health changes that are valuable to you. Patients often leave feeling clearer about what steps they can take and feel more confident these are within their grasp.
The Primary Care Social Prescribing Service was established in September 2019. Meet our Social Prescribing Link Workers (SPLW):
Emily, Lee, Jessica
SPLW work with patients registered across the North Halifax Primary Care Network over the age of 16. The aim is to build trusting relationships with patients, to improve their health and wellbeing and identify appropriate services to support their needs.
Social prescribing is a means of enabling patients with social, emotional or practical needs to access a range of local, non-medical services, often provided by the voluntary and community sector. In other words, it is about health and care professionals (GP, nurses, social care etc) providing patients with “prescriptions” for activities rather than drugs and medical treatment. A link worker assess the patient by using “what matters to me (the patient)” approach, to agree a plan to help improve their health and wellbeing. Time spent with each person will depend on their needs and ranges from simple signposting to a full assessment and support.
You can find out more about social prescribing by accessing this link:
Visit the Kings Fund
A patient can be referred to a Social Prescribing Link Worker by requesting an appointment themselves through their GP surgery, by being referred by another service or agency they are already working with or by another PCN member of the team.
In addition to social prescribing, SPLW lead on specific projects – signposting patients with recent diagnosis to relevant services in the community:
– Cancer care reviews
– Carers project
– Collaborative working with our partners for North Halifax Community Health and Wellbeing Partnership.
– Mental Health Transformation Programme
– Vulnerable patients project
The Phlebotomist works in surgery by an appointment Tuesday – Friday 10:00 – 16:00.
Patients told us that they would like phlebotomy in the afternoon. We listened and invested in this very popular service.
Meet our Podiatrist – Mohammed
Any problems with feet from infections and ingrowing toenails to problems walking to foot pain. Our PCN offers minor surgery every month.
Podiatry involves the assessment, diagnosis, and treatment of conditions related to the foot, ankle, lower limb, and its associated structures. It incorporates both conservative care for existing complaints, and corrective management for acute and chronic conditions.
Podiatrists can treat a wide-ranging list of complaints. Often, the presence of a conservative complaint can be linked to a problem that would benefit from corrective management and vice versa.
Podiatry also plays an important role in the management of long-term health conditions such as:
Peripheral neurological deficit
Peripheral vascular disease
During your initial consultation, the podiatrist will perform a full subjective assessment, listen to your complaint and details of the presenting problem. Documenting all medical history, including your general health and lifestyle.
They will then perform an objective assessment with your consent. Skin color, tone, texture, and temperature will be observed, alongside a vascular and neurological assessment to identify any deficit which may be underlying or linked to any pre-existing medical complaints.
If relevant, your podiatrist may also perform a biomechanical assessment, observing you standing, walking, and non-weight bearing. Ranges of motion will be assessed, and leg length observed. Hands-on examination of the affected areas may be necessary.
Your podiatrist will then discuss their findings, form a diagnosis and discuss treatment options available. They will talk through an appropriate management plan, including you in the decision-making process at every opportunity.
Our sample collection team (Keith and Ian) enables us to provide an afternoon blood taking service (phlebotomy). They work tirelessly to provide the service 52 weeks a year. This is not an NHS funded service but one that practices invested in.
Meet Bethany, our Health and Wellbeing Practitioner from South West Yorkshire Partnership.
Bethany provides assessments for Talking Therapies and if deemed suitable will book you for a course of Talking Therapy.