Care Home Project

(SWCCG)
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Care home project

The aim of this project was to enhance quality of care for care home residents, by improving the coordination and management of each individual residents care needs through the production of a Clinical Management Plan (CMP).

The CMP is one single individualised patient plan , available for any health care clinician treating the patient and includes details of a residents care needs and preferences in regards to end of life care or avoidance of hospital admission. The CMP facilitates residents living well by ensuring their CMP is agreed between the resident, Community Nurse Practitioner (CNP), care home staff and the GP. It remains with the patient at their care home, allowing direct access to ambulance crews and GP Out of hour’s services for rapid support close to home.

As part of the project, the Enhanced Primary Care (LES) required GP’s to have weekly contact with the CMP’s to review the management of complex care patients. In addition, pharmacists provided an annual medication review for all residents and dietetic support was available as required.

The project aimed to:

Enhance patient safety of older people by providing 24/hour rapid clinical advice and support to carers /care home staff who may or may not have a clinical background.
Enhance quality of care with a reduction in A&E attendances and emergency admissions
To support the early discharge of residents from hospital to their care home, reducing hospital admission whilst prioritising effective discharge planning and support.
To deliver improved patient satisfaction through effective clinical management and communication.
Further develop the existing scheme with appointment of additional CNP’s