Care Homes at Scale

This service commenced on 19th August 2021. We currently have 37 Learning Difficulty (LD), Mental Health (MH), dementia and older people’s care homes under this model.

The service runs with a GP clinical lead and an advanced nurse practitioner (ANP) lead supported by two integrated care coordinators (ICC). There are structured multi disciplimnary teams (MDT) covering four neighbourhoods, each neighbourhood is covered once per month.

The MDTs are tailored for each patient cohort and include representation from Norfolk and Suffolk Foundation Trust (NSFT), adult social services, specialist occupational therapy (OT) and physiotherapy (PT) services, pharmacy support as well as the ONP GP, ANP and ICCs.

Structured medication reviews are carried out by the clinical pharmacist when required. The GP carries out a thorough review of the full records of all patients referred to the service. Part of this review is to ensure relevant annual checks have been completed and to identify any issues or concerns that should be raised within the MDT meeting. This can include any safeguarding concerns or behavioural changes in the patient which may indicate an underlying problem. The MDT acts as advocates for these patients in vulnerable groups by raising and discussing concerns to mitigate risk to the patient.

The team has received very positive feedback from care homes, patients, relatives and other healthcare professionals for the work carried out within this service.

We are looking to expand this service to other care homes across Norwich and for the team to work alongside the HVS and GPHVS.