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Communication and collaboration in a complex care team

Communication and collaboration in a complex care team

What’s great about multidisciplinary teamworking? Nursing in Practice finds out from several members of a team supporting patients with complex care needs in Somerset 

Nurses are among those working in three closely coordinated and responsive complex care teams (CCTs) in primary care networks in Somerset. The model began in Frome Medical Centre PCN, before Central and West Mendip PCNs adapted it to their needs.

The CCTs help patients manage their health and social care needs and live as independently as possible, which includes supporting families and carers. They do this in partnership with providers such as GPs, district nurses, mental health specialists, adult social services, occupational services and local hospitals. 

This integrated model is delivered to patients with comorbidities, palliative care needs or other vulnerabilities, and those who need longer-term support after hospital discharge.

Based on a compassionate care model, it has achieved a 14% reduction in hospital admissions (against a 28% rise across Somerset) and a 21% fall in healthcare costs – which the team says is a welcome by-product of working together for patients. 

Nurse team leads vital to successful collaboration
A vital factor has been three nurse CCT team leads collaborating to share best practice: Jo Trickett, nurse practitioner (NP) at Frome Medical Centre; Jacqueline Cross, nurse at CCT West Mendip; and Sarah Stone, NP in Central Mendip. 

Mrs Trickett, who won the General Practice Nurse Leadership Award at the Southwest Practice Nursing Celebration & Awards last year, puts the service’s ongoing success down to communication and being empowered to share and act on good ideas. 

Ms Cross cites the idea to hold regular frailty meetings managed by the CCT, involving secondary care consultants and the wider multidisciplinary team. Patients are reviewed holistically and referrals and actions are managed locally in a timely manner, helping to reduce admissions and stress on secondary care.  

Ms Stone recalls a vulnerable patient waiting to go into a care home, whose family and carers were struggling. ‘I arranged a meeting at the patient’s home with all the health professionals involved.’ A plan of action was agreed and the patient was in a care home within four days. The patient and her family were at the forefront of the meeting and were very happy with the outcome.

The benefits of working together

Jo Trickett, complex care team lead and nurse practitioner, recognises the value that a close working team with a problem-solving approach can bring to providing patient-centred care for vulnerable people who need it most.
She says: ‘The integrated complex care model was developed to connect and support patients and their families or carers with complex health and social care needs. Not only does it provide holistic wraparound care to patients and reduce admissions, but its collaborative nature has also enhanced the working lives of the multidisciplinary professionals who work within this model.’

The GP
Dr Helen Kingston, a senior GP partner at Frome Medical Practice, was behind the development of a system that has allowed a practice with 30,000 patients to provide holistic care and boost job satisfaction for staff. 

‘Somerset gave us that devolved leadership and allowed us to develop, from the ground up, the services that we felt we needed,’ says Dr Kingston. 

‘We’re a big team with lots of people specialising in different areas but, probably more than a small practice, we had issues with continuity and size. 

‘As a GP, you recognise how much relationships matter, how important continuity is, particularly for that risky cohort who are frail, vulnerable, and may have mental health problems or difficult life circumstances. Knowing the backstory really helps ensure you’re doing what matters most to that individual.’ 

As a result, Dr Kingston built a system within the practice to embed communication between separate services, so patients did not have to repeat their story. This began with multidisciplinary meetings to identify and discuss patients who might be ‘falling through the net’ and require additional support. 

When patients discussed problems that might indirectly affect their health but were outside her scope as a GP, she could signpost them to resources or refer them directly to health connectors. From this, a practice complex care hub was developed, a model that has gained international attention. It has subsequently been adopted and adapted in Central Mendip PCN, and West Mendip PCN is looking to expand the model even further.  

The system was designed to empower healthcare professionals to take ownership of problems rather than sitting rigidly within their job role, Dr Kingston explains. Developing relationships with other allied professionals, district nurses and community services has allowed gaps between services be identified.  

‘That is really important for retention, recruitment and feeling you’ve done a good job when you go home at the end of the day,’ she says. She acknowledges, though, that there is always more that could be done. 

‘Austerity is not helping people, there is a lot of uncertainty in people’s lives,’ she points out. ‘The funding of social care is a difficulty, and we continue, like every practice, to have difficulty recruiting and retaining staff because of workforce issues. But we’re really lucky to be supported in developing this model and by the ICS to continue moving forward to deliver it.’ 

The nurse practitioner
As a nurse practitioner, Julia di Castiglione looks after nursing and residential care homes within the CCT, alongside nurse practitioner colleagues Becky Young, Sarah Wescome and Lorrae Aldaghma. She says her work has ‘dramatically changed’ since she started seven years ago, before the model was established. 

‘There is whole-team support, which I didn’t have before. There is always somebody to speak to and support me; between us we have created a strong set-up.’

Now working part time, Ms di Castiglione says the team is there to support and cover each other. She adds: ‘We’re picking things up that much more quickly. It’s stopping people going to hospital unnecessarily.’ 

The mental health nurse
Tracey Glen-Travers, mental health nurse practitioner at Frome Medical Practice, works with two other mental health practitioners at the practice and alongside the CCT, arranging dementia and mental health reviews, helping with discharge summaries, care plans and anticipatory care.

She says working with colleagues such as health connectors, nurse practitioners and GPs has been helpful, particularly when many patients held back on seeking help during the pandemic.

Now, she says, the cost-of-living crisis is proving particularly hard for her patients, citing the case of an elderly man who cancelled his Lifeline subscription because he couldn’t afford it, despite being prone to falls.

‘That’s where the CCT and health connectors are very creative in terms of trying to support you,’ says Ms Glen-Travers.

She adds: ‘You’re given a job to do with restrictions placed on you and you’ve got the freedom to think about it within the team. I think that makes for a healthy work environment and a positive experience for the patient.’

The discharge liaison nurses
With the Government and the NHS focused on speeding up hospital discharge, Somerset is already demonstrating the impact of effective communication between secondary and primary care teams on reducing lengths of stay. 

Clare Vause and Susannah Bruce are discharge liaison nurses at the Royal United Hospital in Bath, working on behalf of Somerset ICB to support the CCTs. Their role is to identify patients with complex health or social care needs, arrange safe discharge planning and alert the CCTs if additional support will be required in the community. This planning and communication helps reduce readmissions.   

‘It feels much more integrated,’ Ms Bruce says. ‘We are lucky to have information from CCTs: all that collateral and history is really helpful.’

And it works both ways: ‘We get a flag from the CCT if they’re worried about someone,’ she says, adding: ‘Those details that you might not know – home and social circumstances – it’s really helpful for our therapist and doctors.’ 

The paramedic
Advanced paramedic practitioner Andre Pilling joined the CCT at Frome Medical Practice more than a year ago and supports the team by doing home visits for housebound patients identified by the CCT as having ongoing complex physical and or mental health care needs. He also assists with acute same-day presentations at Frome Medical Centre. 

‘My role is to do telephone triage and  urgent visits where appropriate,’ Mr Pilling explains. ‘I do a lot of post-falls, risk assessments – sometimes I help with picking a patient up from the floor after a fall. 

‘The role involves collaboration with other health and social care multidisciplinary teams serving Frome Medical Centre, such as Rapid response, district nurses and the local hospice. 

‘Patient feedback is positive. They like the fact that they’re seeing the same clinicians all the time due to our dedicated team.’  

Pictured above: members of the complex care teams. Back row (from left): Jo Trickett, complex care team lead and nurse practitioner; Jo Plenty, care co-ordinator; Dr Dan Cook, GP; Becky Young and Julia di Castiglione, nurse practioners; Andre Pilling, paramedic. Front row (from left): Emma Poole, care co-ordinator; Dr Helen Kingston, GP and senior partner, and founder of the Compassionate Frome Project; Sarah Wescome and Lorrae Aldaghma, nurse practitioners.


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