The challenge
Aligning the system and focusing on Community Resilience
In 2020, the Northamptonshire health and care system commissioned a diagnostic to look at how health and social care was working for its residents. The system recognised that it could be achieving better outcomes for its growing elderly and frail population. The results of the diagnostic showed that a full system transformation would be beneficial for residents, staff, and finances alike.
The community resilience pillar of the iCan programme involved many interrelated projects. A few of the changes made were:
A truly integrated, nationally recognised, community-based Age Well team, bringing together health, social care, and the voluntary sector, providing a strengths-based approach to support older and frail people in the community A frailty model has been adopted across all Primary Care Networks (PCNs) in Northamptonshire. GPs are leading extended reviews with over 120 patients and carers per month allowing for proactive, preventative care plans to be put in place with the support of multi-disciplinary teams. The PCN Age Well team members proactively reach out to patients in the community to provide practical support to over 300 newly identified people per month.
Connecting the 2-hour Rapid Response team to EMAS to support people at home and reduce hospital admissions A pathway now exists for East Midlands Ambulance Service (EMAS) to directly refer a Rapid Response team to calls without sending an ambulance. The response team takes over 800 calls per month, with 80% of the calls being seen within two hours of the call (the national target is 70% within two hours). Only 55% of falls-related EMAS calls now result in acute attendance; 98% of non-injurious falls referred by EMAS to Rapid Response have been successfully treated at home and do not result in an admission to hospital. Reducing delays to discharge by providing rehabilitation equipment in the community The introduction of equipment stores, which hold a stock of key items, at community hospitals has allowed for patients to be discharged when they are ready. Prior to these changes discharge was often delayed due to individuals waiting for equipment to take home for rehabilitation. Equipment is now available at the point of discharge ensuring that individuals are not in hospital for longer than necessary due to equipment delays.
The iCAN programme
Together, teams across the system and Newton embarked on iCAN, a transformation programme aimed at improving outcomes for residents and staff. The three key areas that make up the iCAN programme are: Community Resilience: Supporting older people to live independently within their community. Flow and Grip: Reducing the amount of unnecessary time spent in hospital and ensuring that residents are equipped with the right information and right support when they leave hospital. Frailty Escalation and Front Door: Ensuring that residents are assessed swiftly and treated effectively when needed, to allow them to remain independent.
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