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Richmond Community Healthcare in Partnership

'Richmond Community Health in Partnership' logo

Richmond Community Healthcare in Partnership (RCHiP) is a new ground-breaking new partnership between GPs from Richmond GP Alliance (RGPA) and Hounslow and Richmond Community Healthcare NHS Trust (HRCH). 

Richmond GP Alliance is a collaboration of every GP practice in the borough of Richmond, whilst HRCH provides the majority of NHS community services in the local area.

As part of this new initiative which launched in December 2016, Richmond GPs and community NHS clinicians are working together more closely than ever before to deliver better out-of-hospital community services for adult patients. 

Key to the success of the new partnership is achieving the "outcomes" that matter most to patients. Clinicians from the new partnership have been working with patients and local people to identify the health needs and outcomes that really matter to them. This work has been used to make improvements to "patient pathways" for the various community services involved. 

A "patient pathway" is the route that a patient will take from their first contact with the NHS (usually through a GP), through referral to other health services, to the completion of their treatment.

Areas of focus:

The new RCHiP partnership will initially focus on improving health services and patient pathways for the following community health services:

  • Cardiology

  • Diabetes

  • End of life / palliative care

  • Frail elderly care services

  • Respiratory care

  • Urgent care services


Latest updates:

Latest update: 21 March 2017

Improving cardiology care for Richmond patients 

Local cardiology specialists, including Richmond GPs, clinicians from HRCH, Kingston Hospital NHS Foundation Trust and Chelsea and Westminster NHS Foundation Trust – together with patient representatives, have been working together to understand how cardiology services for Richmond patients can be improved.  

As part of this work, the team has developed plans to ensure that Richmond patients who require cardiology care can receive more joined-up care and improved access to local services in the community.   

The objectives for improving local cardiology services are to:

  • Improve services for people living with cardiovascular disease (CVD) by joining up care and services between GPs (primary care), community care and hospitals – whilst improving links between providers

  • Improve the understanding and confidence of patients to self-manage their condition

  • Improve patient’s quality of life and satisfaction with the care they receive

  • Reduce unnecessary hospital admissions

  • Learn from, improve, and expand on what's already working well for cardiology services in Richmond

  • Improve the identification of patients with atrial fibrillation

  • Provide more and better cardiac rehabilitation services

The newly redesigned cardiology service in Richmond will provide all eligible patients with a person-centred service that improves their health and wellbeing - ensuring they get the right medications and treatment, whilst improving quality of life and minimising the risk of future cardiac problems. 

Changes to cardiology services in Richmond:

The first stage of the plans will see a Specialist Community Heart Failure Nurses working in the community to support heart failure patients to self-manage their condition more effectively, ensure they get the right medications, and provide access to other cardiology and cardiac rehab services.   The community cardiac rehabilitation service will also be improved to ensure patients are receiving care in line with best practice guidelines.   

Latest update: 17 March 2017

Convenient, local care & support for people with diabetes

Local diabetes experts - including GPs, diabetes specialist nurses and patient representatives - have been working together to develop a new “patient pathway” for diabetes patients in the London Borough of Richmond.

A "patient pathway" is the route that a patient will take from their first contact with the NHS - usually through their GP - through referral, to the completion of their treatment.

The new diabetes patient pathway for Richmond borough will help local people with diabetes to get more convenient access to high quality diabetes care, closer to home – instead of having to travel to their nearest hospital.
It aims to ensure patients receive improved diabetes care and access to local services, whilst achieving long term reductions in diabetes related hospital admissions. 

Range of improvements

As part of the range of improvements being introduced, diabetes care will be delivered through clinics held in local hubs within the areas where people live. Patients will be able to either receive their care from specialist community diabetes teams, locally - rather than in an acute hospital - or to access more of their care directly from their own GP.   

As a result, patients will benefit from more convenient, consistent and well-managed care for their diabetes, with their GP overseeing the routine management of their condition. Patients who are currently referred to hospitals for their diabetes outpatient care, who do not need to be, will be referred back to their GP or a local hub wherever possible.
 

In addition, a telephone and email advice line is being introduced for Richmond patients and clinicians to support people with diabetes to manage the condition more effectively.  

Diabetes psychological support for patients

People with long term health conditions, including diabetes, commonly experience mental health problems such as depression and anxiety - which can affect both their quality of their life and how they manage their condition. 

Alongside the improvements being made to the Richmond diabetes service, Richmond Wellbeing Service is now offering a psychological support service tailored for people with diabetes in the borough, as part of an 18 month trial.  

If you are a diabetes patient and feel you would benefit from a referral to the psychological support service from Richmond Wellbeing Service – please speak to your GP in the first instance and bring with you this form to complete with your GP.

GPs, community clinicians and hospital staff have been working to support patients and their families who are nearing the end of their lives in their preferred location; whilst reducing the number of emergency hospital admissions for patients with long-term conditions by providing more ‘out-of-hospital’ palliative care services.

The team identified a number of objectives for improving palliative and end of life care for patients and local people: 

  • Placing an increased focus on providing care and services for patients who are in their ‘last year of life’.

  • Joining up care services provided by GPs, hospitals and community health services - with shared ownership for providing end of life care services.

  • Coordinating and facilitating ‘open discussions’ between the patient, their families/carers - and the various health and care services providing end of life care.

  • Ensuring continuity of GP care across different care settings.

  • Strengthening communication with patients and carers.

  • Extending bereavement care services in community.

  • Reducing unwanted variation in care between different services or care providers.

  • Coordinating advance ‘care planning’ across GPs and hospitals.

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.

 

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.

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.boultbee@hrch.nhs.uk or Sasha Pearce, senior clinical transformation lead for Frail Elderly on sasha.pearce@hrch.nhs.uk or tel 0208 973 3109. 


Other initiatives being developed include: 

Care Homes – Improving care and quality of life.

  1. 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.
  2. 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.
  3. 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.
  4. Standardising GP support at the Care Homes: Investigating how best GPs can support the Care Homes in a uniform way across the borough.
  5. 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.
  6. 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.

Latest update: 21 March 2017 

Joining-up respiratory care services

GPs and clinical specialists from HRCH, Richmond GP Alliance, Kingston Hospital and Chelsea and Westminster NHS Foundation Trust - have been working together with patient representatives to look at how respiratory care services in Richmond can be improved to achieve better outcomes for local people with respiratory conditions.

The team identified a number of priority areas to address:

  • Joining up patient care by strengthening links between the various respiratory care providers  - such as local hospitals, GPs, and the community service providers

  • Achieving earlier identification of patients with COPD to improve outcomes

  • Improving patient safety by delivering care in the most appropriate setting

  • Supporting patients to self-manage their conditions more effectively

  • Provide more consistent care for patients

  • Reducing the number of unnecessary hospital admissions

     

HRCH will work collaboratively with GPs and local hospitals to improve services for people with respiratory conditions, as well as strengthening links between those providing care. 

From 1 April 2017, as part of the re-designed service - patients with mild to moderate COPD will benefit from self-management educational sessions and more convenient, local care provided at their GP practice; whilst patients with severe COPD will be treated by HRCH’s community respiratory care team.