Richmond GPs, local hospitals and community health clinicians have been working together with patient representatives to improve care for frail and elderly people in Richmond borough.
Following a review of the existing care on offer - a range of new services are being created to support local elderly people, including two types of Senior Health Clinics - to help local healthcare professionals to assess and plan elderly people’s health and social care needs, working closely alongside the individual.
1.Senior health clinic in Teddington
At Teddington Memorial Hospital there is a clinic with a pharmacist, consultant, therapist and nurse to assess the patient.
This clinic may be best for complex patients who have multiple health needs - including lots of medications, difficulty with physical tasks and general ill health, leading them to being frail and at risk of hospital admission.
The patient will attend the clinic for an afternoon to be seen by all the professionals.
This happens weekly on a Thursday afternoon currently and is a pilot until the end of May.
Download the senior health clinic referral form here.
2. Virtual clinic
A new 'virtual clinic' uses a web-based video conferencing tool that allows us to invite any health or social care professional, the patient and or carers - plus any voluntary sector colleagues (as appropriate), to participate in a review and planning meeting for the individual concerned.
The virtual clinic may be best for a moderately frail person having difficulty coping at home due to complex needs and would like a multi-disciplinary problem solving session to look at new solutions to managing their care -especially if they are starting to fail to cope at home and a hospital admission or residential care home placement is imminent.
If the person does not have an actual assessment at this point, the virtual clinic is discussion based between the various health professionals involved, with a care plan written and agreed at the end.
The virtual clinic is starting on 31 March and will happen three times a week, on Monday, Wednesday and Friday between 1-2pm.
Download the virtual clinic referral form here.
Both these clinics are linking closely to other services such as the Falls Clinic so the individual gets the most comprehensive and appropriate service for their needs.
If you would like any help or advice about these new frail elderly services, please contact our administrator, Nicole Boultbee on Nicole.firstname.lastname@example.org or Sasha Pearce, senior clinical transformation lead for Frail Elderly on email@example.com or tel 0208 973 3109.
Other initiatives being developed include:
Red bag scheme
HRCH launch Red Bag Scheme for hospital transfer pathway
The red bag initiative focuses on elderly residents from care homes in Richmond who are transferred to A&E at Kingston Hospital and West Middlesex University Hospital by London Ambulance Services.
The initiative, which will launch early June, has been designed to support care homes, the London Ambulance Service, Kingston Hospital and West Middlesex University Hospital to meet the requirements of the NICE guidance on transition between inpatient hospital settings and care homes.
The red bags contains personal effects such as dentures, glasses, hearing aid and toiletries, as well as a change of clothes and pair of slippers so the individual can function, get out of bed and be ready to go home as soon as they are able. The red bag initiative will help people living in Richmond care homes to receive quick and effective treatment should they need to go into hospital in an emergency.
The bags also contain standardised information about the resident's general health, any existing medical conditions they have, medication they are taking, as well as highlighting the current health concern and important personal details about the individual. This means that ambulance and hospital staff can determine the treatment a resident needs more effectively.
This will save time during the transfer of the resident from care home to ambulance and from ambulance to A&E. It will also allow A&E staff to make more informed decisions about the patient, as they will always be aware that she/he is a care home resident.
HRCH developed the red bag initiative together with Richmond Community Health in Partnership, Richmond CCG, Kingston Hospital NHS Trust, Chelsea and Westminster Foundation NHS Trust – West Middlesex Hospital, London Ambulance Service and representatives of the Care Homes in Richmond.
Care homes – Improving care and quality of life.
- Hospital Transfer Pathway/Red Bag Scheme: When a care home resident becomes unwell and needs to be taken to hospital, they will be transferred with a set of standardised paperwork which includes all necessary health and social care information about that person to support staff in providing the right care. This is contained in a “red bag” which also holds their medicines and personal belongings. The red bags are currently being made and should be ready for use at the start of June. We are currently working with the Care Homes and Hospitals to make sure everyone knows about how to use it.
- Support Worker Training: This is to provide essential training to unqualified staff to help them recognise the early signs of disease or ill health, such as dehydration or infection so that early diagnosis and referral can be made before serious consequences occur such as a fall or confusion. This is in the early stages of planning.
- Care Home Support Team: In conjunction with the training, looking at having a dedicated team of clinicians to support the borough’s Care Homes, e.g. pharmacist, nurse, dietitian etc. This is in the early stages of planning.
- Standardising GP support at the Care Homes: Investigating how best GPs can support the Care Homes in a uniform way across the borough.
- Care Navigators in A&E: A pilot study involving Care Navigators is looking at providing a free, impartial and confidential service to older people in Richmond. They will be based or in contact with local hospital A&E departments to work with people who have avoidable attendances at A&E, i.e. they are sent home without treatment as they could have been supported elsewhere and had no need for acute input.
- Care co-ordinators with medical knowledge will advise and support frail elderly people in accessing appropriate services, implementing care plans and being a single point of contact for individuals, carers and services.