Primary care is central to managing good quality care for an ageing population. Whether living independently or in care homes, older people with long-term complex conditions require continued health and social care support. On the face of growing demand and pressures on cost containment, both the NHS and local authorities are working together to create more efficient, but above all, better and more integrated care experiences for older people.
Integrated care models continue to gain support. At today’s King’s Fund event entitled “Enhanced health in care homes”, the NHS Forward View for integrated care was analysed in light of on-going integration efforts in areas of specific relevance to care homes and care in the community: including medical reviews, medication reviews and rehabilitation. From the perspective of policy makers and providers, the challenge in delivering truly integrated care is significant and complex.
But if we adopt the point of view of people receiving personalised care as they travel between the worlds of healthcare and social care, it’s easier to make decisions about service design and integration. Seeing the journey through the eyes of the person we can learn to avoid the chasms, endless discharge and admission forms and the clunkiness of transitional care. As David Oliver puts it on this article about the timeliness to tackle integration in Care Homes: Care Homes sit at the interfaces between acute, primary and community, housing, mental health and palliative care – it’s a very complex web.
Communication across these domains fails too often – seemingly small bits of personal information getting lost, the same question being asked repeatedly by care professionals that could have already been informed of the answer, repeated data entry or in the worst case, inconsistent or incorrect information ending up impacting medication and the treatment. We believe some of these locked doors in a long corridor of real life care can be opened simply and effectively by a mobile working ecosystem for health and social care. Let the circle of care talk – so the district nurse can see that a carer visit is scheduled, the carer can see what medication is due, a daughter can be reassured that a visit took place and can see the outcome. And critically, care staff can rest assured that the medication reflects the latest change the GP did to a prescription.
This is how Nourish works in residential care homes and it is working today. Centred all around the person who needs care, the carers, the care managers, the family, a visiting GP, can all see and understand the person, their care plan, their needs, what happened to them today, last week or the month before. Families, carers and people receiving care are telling us the difference that makes, and their stories drive us to continue working to make integrated care communicate and work better, every day.
If you run a GP practice, a care home or an integrated care team and would like to discuss how we could help please get in touch.