Pilot project shows value of integrated care to Manningham patients

A pilot project to support patients with long-term conditions through more joined-up care has proved a real success in Manningham.

As one of the pilots for Bradford’s integrated care for adults programme, a group of six GP practices in Manningham has piloted a project to look at how NHS and social care services can provide care within communities and prevent avoidable stays in hospital.

The practices, part of Bradford City Clinical Commissioning Group (CCG), identified 20 patients with the most complex and high risk needs – involving long-term conditions such as diabetes, asthma, heart problems and chronic obstructive pulmonary disease (COPD) - who frequently end up at hospital.

The project looked at whether these patients could have been supported better to manage their long-term conditions with focused health and social care input – looking at the patient’s family and support networks as well as their clinical needs.

With the support of a community matron, from Bradford District Care Trust, and a community coordinator, the practices worked with the patients over several months to build a picture of their world and how different services could support them to stay well and independent.

By taking time to visit the patients and speak to them and their family, the team soon discovered any gaps in their care; what carer support was available; and if there were any other issues, such as mental health problems, which made the patients more likely to attend A&E.

Dr Raf Rashid, Bradford City CCG’s lead for integrated care, said: “I’m surprised and very pleased at how well the project went; it really showed the value of social care and community input in the lives of certain patients whose needs are more than just clinical.

“The team was able to look in depth at a patient’s home life and identify where extra support could make a difference to how they feel about themselves, and hopefully make them better able to cope with their medical condition. The time invested in looking at a patient’s whole situation and linking with support services certainly pays off in the long-term with reduced demand on NHS services and a better quality of life for the patient.

“We found that simple things like encouraging a patient to join in activities at a day centre, or giving families some respite care, can change a patient and their family’s focus in a very positive way.”

The project showed that identifying patients with the most complex needs – and helping them to remedy issues before they become urgent and lead to unplanned hospital or care home admissions – can have far-reaching benefits.

This approach enables people to keep living at home, with all the things that are important to them within easy reach, and also keeps hospital beds free for genuine emergencies.

The Manningham pilot project has now ended but the practices are continuing with the integrated care model as it has been welcomed by staff and patients. The practices have learnt the value of looking at a patient’s whole needs and supporting them by working in a more coordinated and focused way with partners in social care and community groups.

The team responsible for helping the Manningham patients are just one of many initiatives in the district that aim to provide care within communities and prevent avoidable stays in hospital. Groups of GP practices have come together to work with community nurses, social services and voluntary groups to help coordinate better locally-based care across organisations.

To find out more about integrated care, visit: http://www.bradfordcityccg.nhs.uk/news/what-is-integrated-care/