We caught up with the Nurse/Nursing Team of the Year Award shortlist ahead of this year’s General Practice Awards ceremony to be held on 8 December in London.
The third entry under the spotlight from this year’s shortlist of seven is the Healthy Hyde PCN team of Complex Care Nurses.
The team has a firm belief that strong, effective communication lies at the heart of its successes. As an organisation, Healthy Hyde has strong relationships with all of the GPs at the eight practices it covers, allowing team members to get advice for its most complex patients whenever required.
The complex case nurses aim to provide a consistent level of service for all patients living in a 24-hour care setting. This means equity of care in the 13 care homes covered, removing the risk of a ‘postcode lottery’.
The Healthy Hyde PCN dementia case management service aims to care for those living at home with dementia. A dedicated nurse will provide active case management, formulating personalised care and support plans to ensure the patient receives the right care at the right time in the right place.
The team works with other groups and organisations to locally support and meet the health and social care needs. The aim is to provide a ‘one stop shop’ for patients living with dementia and their carers. The offer of support is provided from the point of diagnosis to the end of life.
The team also has a full multidisciplinary approach, enabling it to call upon the urgent action clinic or home visiting service run by paramedics if someone becomes acutely unwell.
The team has carried out 954 comprehensive, multi-dimensional, holistic assessments to consider individuals’ health and wellbeing needs. This has facilitated shared decision making and planning of care and treatment, addressing the concerns of patients, their carers and families. This process has also helped identify future needs and goals and has assisted in the development of advanced care plans.
With a reduction in hospital admission of 20 per cent, the team’s proactive approach to care has proven itself to be an innovative and flexible way of working to meet the vision of the NHS long term plan.
The goal is to empower patients to have a say in how their care is managed both now, and in the future, allowing them to live well and maintain control of their own health journey.
Over the past year, the nursing team has organised weekly MDT meetings with various professionals such as GPs, care home managers, social care, district nurses and domiciliary care providers, to establish a collaborative care approach to frailty across Hyde. This enabled the team to gain a deeper understanding of the most frail and vulnerable patients, and also allowed members to voice any queries or concerns with the relevant organisations and vice versa.
To further extend these relationships, the team is currently working on improving data sharing between organisations.
What they said
One care home manager described a member of the Healthy Hyde team as ‘organised’ and ‘an asset to her role’.
The manager said: ‘She thinks outside the box when supporting the elderly residents in our care. She is approachable and will always go the extra mile to help’.
The team member had been involved in MDT meetings for the home’s complex residents and the manager said this had ‘really helped us to get the right support’, and that ‘all professionals could learn’ from the Healthy Hyde team member.
Last year, Wales-based general practice nurse Janette Morgan won the Practice Nursing Award after demonstrating her impact on chronic disease management in her locality.