Care Home

Lytham St Annes Primary Care Network Care Home Team (LSA PCN CHT)

The LSA PCN CHT have a multi skilled work force consisting of:

  • Specialist occupational therapists
  • Trainee advanced clinical practitioner (TACP)/first contact practitioner
  • Health care assistant (HCA)
  • Health and wellbeing coach (HWBC)
  • Chronic disease management practitioner
  • Pharmacist
  • GP clinical lead 
  • Non clinical care coordinators.  

LSA PCN CHT provide  proactive home rounds to reduce crisis GP calls from care home and reduction of resident conveyance and admission to hospital 

Clinical Services Provided by LSAPCN Care Home Team 

Holistic assessment by a clinician for deteriorating residents who are not acutely unwell  

  • Comprehensive Geriatric Assessment (CGA) 
  • Complex discharge reviews 
  • Complex Assessments – for MDT  

Mobility Assessment 

  • Environmental assessment 
  • Assess and prescribing equipment 
  • Assess and prescribing exercises 
  • Falls prevention advice 
  • Signposting/referrals – EPC/Falls/LCC 
  • Wheelchair assessment and referral 

Mental health 

  • Support and advice for residents with low level mental health concerns 
  • Screening/triage for referrals to secondary mental health services 
  • Liaison with specialist services 
  • Personalised care and support plan 
  • Low level anxiety/activity setting/goal setting 

Dementia 

  • Cognitive screening and where clinically indicated referral to memory assessment service 
  • Support and advice re behavioural and psychological symptoms of dementia 
  • Personalised care and support plan 
  • Liaison with specialist services and facilitating referrals to secondary mental health services when indicated. 

End Of Life 

  • PCN representative attend GSF meetings on a monthly basis to discuss deteriorating or improving residents. 
  • DNACPR 
  • Coordination of end of life – GSF changes and ceilings of treatment discussions 
  • Liaise with relevant services to support end of life care – e.g. GP, DN’s, Care Home, Family, Residents, Trinity etc 
  • Advanced care planning including EPaCC’s 

 ECG 

  • Non urgent routine ECG’s  

Bloods 

Routine bloods – any bloods non urgent to be completed by PCN that EPC don’t have capacity for:

  • Referral to memory assessment services bloods
  • Outcome of MDT’s 
  • Development of personalised care and support plan (PCSP) 

Oral Health Care 

  • Education and support including oral health care initiative 

Hydration & Nutrition 

  • Education and support 
  • Referral to dietician if required.         

Referrals 

  • Sign posting/completing referrals if indicated. For example: bladder and bowel, dentists, Liaison with GP, EPC, Falls etc
  • District Nurses for skin and wound care and skin and leg ulcers 
  • Multi-disciplinary team (MDT) meetings to discuss a complex residents 

Quality Improvement 

Projects e.g. Falls pathway, severe mental illness and chronic cardiovascular disease, last 1000 days, reducing hospital admissions, dementia diagnosis in primary care 

  • Care Home resource packs 
  • Telephone triage line for PCN 

Working collaboratively with care homes 

  • Build relationships  
  • Evaluation and feedback to ensure the service is meeting the needs of the care home resident population 

Care coordination 

  • Weekly home rounds 
  • Telephone triage line 
  • Navigate and coordinate residents care including referrals and managing enquiries  
  • Personalised care and support plans 

Weekly Home Round 

The LSA PCN Care Home Team deliver a proactive weekly “Home round” for the PCN residents who are living in the PCN aligned care homes in order to reduce crisis GP calls from care homes and reduction of resident conveyance and admission to hospital.  

Each home is allocated its own care co-ordinator who will provide a weekly home round. Each week all care homes are contacted via phone or face to face unless otherwise indicated and agreed (for homes that have different requirements). 

Within a weekly home round residents are discussed according to need. The home round should be completed with the home manager/ senior nurse/carer and led by a PCN Care co-ordinator with oversight from the PCN clinical team for any concerns. 

The home round will include:  

  • Telephone contact with minimum of once monthly face to face care home rounds to identify non acute patients, new residents to the home, end of life residents, hospital admissions, discharges, deaths, and falls; and signpost accordingly depending on the identified need or concern raised. 
  • Provide co-ordination and navigation of care and support across health and care services.  
  • Facilitate referrals and conversations to ensure timely care and access to specialists, GPs, community services etc 
  • Ensure that Personalised Care and Support Plans and EPaCCs are initiated for all patients in Care Homes; working with clinical staff to create new plans and update plans as patient needs change.  
  • Refer on to PCN clinicians or specialist services where there is a need. 
  • Identify when action or additional support is needed, alerting relevant clinical professionals, and highlighting any safety concerns. 
  • Refer to MDT. 
  • Follow through actions identified by Clinical Staff or Care Home MDTs, including arranging tests, referrals, signposting etc. 
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