Pioneering Norfolk scheme to care for elderly

A pioneering scheme to give elderly people care closer to home and to bring hospital beds into their communities is to be rolled out across Norfolk.

From next month GPs and nurses at more than 20 practices in northern Norfolk will be able to do more to help older people with illnesses to stay in their own homes, including giving them access to end of life care.

While north Norfolk will be the first area to get the new Care Closer to Home service, NHS Norfolk plans to roll it out in phases across the county.

The project includes creating 'acute community beds' which will give patients the same care, or even better, than they would receive in a hospital, but closer to home.

Health bosses say the scheme is at the heart of the county's plan to meet the health needs of its growing elderly population and will also help to free up hospital beds and reduce bed-blocking.

There are estimated to be as many as 800 frail elderly people in north Norfolk who have complex health and social care needs and who need extra support. They might be prone to falls, have heart and lung conditions or fall ill with infections frequently.

The aim is to provide a greater degree of support closer to where they live, at home or in a setting as close to home as possible. This will help to keep the patients well and living independently or to head off any problems before they get too serious.

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It follows the success of a pilot scheme running in Norwich, Cromer, Mundesley and North Walsham in which 220 older and more frail patients have been offered closer support. Since January, 113 potential hospital admissions have been avoided as a result.

Fo the pilot there were three acute community beds, one at Woodside House Care Home in Woodside Road, Norwich, and two at Benjamin Court, in Roughton Road, Cromer.

From December this will be increased to 12 in total, retaining the one in Norwich, while the other 11 will be housed at Benjamin Court, North Walsham Community Hospital and Aylsham Hospital.

One of the first patients to use the acute community bed at Woodside House Care Home earlier this year was 81-year-old Kenneth Redgment from Little Plumstead, who was admitted for a five-day stay after an infection failed to clear up.

He said: 'I was very impressed, it was very, very good, everything was spot on. The nurses were great and the food was lovely.

'The bed was nearer to my home than the hospital so my wife could visit me more often so I liked that. And the nice thing about it was that the nurse came across a couple of times a day to see me and make sure I was alright.'

Once vulnerable patients have been identified by their GP practices, they will be assigned 'case managers' –community nurses from Norfolk Community Health and Care NHS Trust (NCH&C). The case managers will monitor the patients regularly and ensure that, wherever possible, they are kept well and can stay at home.

In order to keep people independent and in their home for longer individuals will also be assessed for using telecare/telehealth. Telehealth units allow clinicians to monitor a patient's condition via a computer link.

If a patient's health deteriorates then they might be offered secondary care in one of the acute community beds.

Medicine for the Elderly clinicians from the N&N will be offering an outreach service to the GPs and nurses taking part, adding to the weight of expertise at community level.

In addition, volunteer support workers will build a relationship with each patient, offering help and advice.

Sheila Leach, a great-grandmother who lives with her husband, Ronald, in Mundesley, had heart problems and associated walking difficulties and is one of the patients who has been helped by the scheme.

She said at the time: 'It has worked very well for me. I have had a lot of help and I think everyone ought to know about it.

'It has kept me a lot better. My community nurse, Rosy, has helped me get up and walking – I can't praise her enough.'

Mrs Leach's case manager, NCH&C community nurse Rosy Longley, said: 'The benefits for patients has been immeasurable.

'These are people who were found to need some intensive support - if that had not been available they would most likely have had to be admitted to hospital.

'It has, without doubt, helped to remove the need for a lot of patients going into hospital.

'The personal health advisors have been invaluable. As well as flagging up health issues, they have helped the patients to obtain benefits which they were entitled to but often unaware of.'

NHS Norfolk's assistant director of out of hospital care, Wendy Hardicker said: 'We know that this type of approach is what patients want and it works. If they are cared for at home or closer to home then very often the patients are supported, acute admission is avoided, recovery is quicker and confidence increases.'

Mrs Hardicker said the Care Closer to Home project was central to the county's approach to dealing with the estimated rise in elderly people in Norfolk in the coming decades.

Mrs Hardicker said: 'We want to be able to use acute hospitals for what they do best. By ensuring we develop these types of services and develop it also closer to people's homes that allows the actue hospitals to be able to have the capacity to deal with the types things requiring their skills and expertise.'

While NHS Norfolk made great strides in reducing bed-blocking by 75pc last winter, the new community beds could help to ease the pressure even further in the future.

The highest number of patients waiting for a community bed last winter was 22 at the N&N. This compares to the previous year when the highest number of people waiting for a bed was 52.

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