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Steph Elkins, Lead Care Co-ordinator, Derbyshire Community Health Services, takes the hotseat to provide questions and answers on the service provided by the care co-ordinators.

What service do you provide?

“The care co-ordinators’ service covers the whole of Erewash. There’s a care co-ordinator appointed to every GP practice looking after all patients over the age of 18. We will be called in for many reasons - it may be to prevent a hospital admission, the patient may be struggling to manage at home, they may have hit crisis and need help. It’s a holistic approach to care; the GPs cover the medical side of things but as administrators we are there to put everything else in place.

“We have fortnightly meetings which are like a multi-disciplinary team (MDT) meeting. Within the meeting are community matrons, district nurses, social services, mental health, lead GP, occupational therapists, physios and community services and as care co-ordinators we identify patients who may be at risk of hospital admission, might need increased support, or may be coming up to the palliative stage of their illness, and we discuss those patients and
 with everybody’s input we look at what we can put in place to keep them as well as they can be and safe. We look at what plans we can put in place, what referrals we can do – for mental health or for walking aids for example - and we put the plans into action.”

What is the aim of the service?

“Our first initial criteria was to prevent hospital admissions. I think over time the service has just got bigger and bigger. As time has gone on we’ve become more involved with palliative patients so if there is somebody who wants to be at home we help and try to co-ordinate that care. I think we’ve just become the general ‘go to’ person to be absolutely honest. We are seen as the font of all knowledge, we know what services are available and services use us as the hub if they need any information about a patient.”

When was the service set up?

It was set up four years ago. We’ll be celebrating our fifth anniversary in February (2018).

How has it changed things?

“There’s a huge difference been made for GPs - instead of them spending hours on the phone trying to sort things out for patients we can now do that. I think
the main benefit though has been for patients. We’re providing a service that wasn’t there before and giving them the opportunity to have support before it becomes a crisis. We ring everyone aged over-65 once they’ve returned from hospital to ensure they’ve got everything in place they need. Sometimes people think they’re ok in hospital but when they come home we put them in touch with services that can support them with their recovery. They really appreciate the phone call, it shows someone cares and is thinking of them, and they have a contact which family and friends can also use to check on their care.

Where are the care co-ordinators based?

“We’re all based in GP practices. If a practice is quite small, a care co-ordinator might cover two local practices. I’m based at Littlewick and there’s always somebody here every day.”

Who are the care co-ordinators?

“We’re all from different backgrounds. We have got some that were clinically trained, former healthcare assistants, while most of us were previously based in GP practices or have worked in the NHS in some form or other, so we’ve got a good knowledge base. I was a receptionist working in a small practice that dispensed so I know a bit about medication whereas other people have insights from supporting community teams for example so we can pool all of this knowledge.”

What impact are you making?

“We get a lot of feedback from GPs and from patients and they are very thankful for how we’ve been able to help. I know the CCG has done some work looking at hospital admissions and it’s difficult to say what is affecting admissions but we like to think the care co-ordinators are playing their part. We have feedback cards and we do have people giving us compliments. People should always remember the service is here and that we’ll always try our best to help as much as possible for anybody.”

What do you enjoy about your role?

“The best thing is having the ability to help. I think we’ve always been privileged to be in this position,
 it’s knowing you can make a difference. We can just ring somebody up and have a conversation with them and they know that there is somebody there at the end of the phone. If it is a patient nearing the end of their life and they desperately need services you can put everything in place, knowing that they will feel safe and secure. Sometimes it’s just the little things – somebody will ring up and they need a commode or a walking aid and you know you can put that in place and it makes such a difference to them. I’ve always been so enthusiastic about it.”

What difference has the vanguard made to you?

“It has allowed us to have the additional care co-ordinators which were definitely needed. I’m hoping something will be done so we continue to have them after the vanguard programme has ended because without them we would struggle to continue the service, our jobs have just got bigger and bigger.”

Any new projects?

“A piece of ongoing work is that we’re looking at patients over the age of 80 who have not recently been to see someone medical. We’re reaching out to them by letter and phone to see how they’re getting on. They might be fabulously fit 80-year-olds and there’s a lot of them out there that don’t need any help but it’s about finding that small percentage that are at home and really struggling. They might either don’t know how to contact us to get help or don’t want to. It’s about forging that link, doing home visits and seeing whether they need some assistance. We’ve contacted a good couple of hundred people so far. About 30 per cent of people contacted have needed services. Sometimes it can be the case that a family member will answer the phone and they appreciate the fact there is someone they can contact for support if they need. In the future I’d like to bring that age limit down to about 70 but that will depend on staffing resources.”

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RT @NHSEngland: If you need medical advice fast but it’s not an emergency call NHS111 to be directed to the best local medical care for you…

Wellbeing Erewash

by Wellbeing Erewash