Do you want to find groups and support in the community that might help you improve your health and wellbeing? You can find lots of local support from charities to social groups in the Arc Bucks PCN Directory.
People living in care homes should expect the same level of support and care as if they were living in their own home. But this can only be achieved through a collaborative effort between health, social care, voluntary, community, the social enterprise sector and care home partners.
Arc Bucks Primary Care Network provides care services for local care homes under the NHS Network Contract Directed Enhance Service (DES). Clinical and non-clinical staff from each of the practices, and both the access team hubs work closely together with care home staff to deliver a high standard of multi-disciplinary care for all residents.
Framework for Enhanced Health in Care Homes
In 2019, practices across England joined together with neighbouring practices to form Primary Care Networks (PCNs). This was to enable the NHS to deliver better primary care healthcare services by pooling resources and working at scale to help tackling health inequalities.
In terms of care homes, this meant a new way of working would have to develop to incorporate the requirements of the new Network Contract DES and the obligations and responsibilities detailed within the Enhanced Health in Care Homes framework.
The Access Team
The access team comprise a multi-disciplinary team of clinical and non-clinical staff that work for the general practice and the PCN; to work closely with Immedicare and the Care Home staff to ensure continuity of care for each resident and focus on long term proactive healthcare management.
The access team are responsible for putting personalised care and support plans in place for each patient, proactively reviewing patients following discharge from hospital, and conducting annual health care reviews specific to any long term conditions (such as diabetes or hypertension). The access team also liaises with the care home staff, with the care coordinators being their main point of contact. The access team will conduct weekly ward round reviews at all the care homes, to access any follow-up as needed from an Immedicare consultation and to carry out annual health reviews as well as proactive health screening.
The access team can speak to a dedicated GP each day should this be required, as well as meeting for a daily morning huddle to review any points of concern, co-ordinate workload and discuss any arising queries from the home.
The access team conduct regular multi-disciplinary meetings which involve various members of the PCN team, general practice team, Immedicare, district nurses and care home staff.
Weekly Ward Rounds
The access team receive a list of patients ahead of the weekly ward round from the care home staff. The list will contain any residents that require a face-to-face consultation, which is carried out by our PCN community paramedic or physician associate. These registered healthcare professionals are fully qualified and trained to work autonomously whether at the practice, at care homes or on home visits where they would attend to housebound patients.
The majority of the weekly ward round is spent completing annual healthcare reviews and assessments to aid better proactive long term planning and management of resident’s health and wellbeing.
The MDT Meeting
The MDT meeting involves a collaboration between primary care, community healthcare and social care services and where appropriate, VCSE and secondary care-based specialist clinicians. The MDT is structured to include specialists who can meet the individual’s needs. The MDT will likely differ based on the size and type of the care home.
Within the MDT meeting, time is invested in developing strong and trusted working relationships between professionals across organisational boundaries, with community provider and PCN leads discussing and agreeing with care homes what is important to care home staff and residents.
Immedicare
The Immedicare Digital Care Hub was commissioned by the Buckinghamshire, Oxfordshire and Berkshire (west) Integrated Care Board for use across Buckinghamshire County.
Immedicare supports care homes by providing 24/7 access to virtual clinical assessment, virtual clinical supervision and safe supportive care.
It is staffed by a highly skilled multidisciplinary clinical team from a range of specialist fields including; Doctors, Advance Nurse Practitioners, Paramedics, Physician Associates, etc.
Care Homes aligned with Arc Bucks PCN:
| Marlow Medical Group | The Simpson Centre | Wooburn Green & Bourne End Medical Centre | Highfield Surgery | Millbarn Medical Centre |
|---|---|---|---|---|
| Cliveden Manor | Adele House | Cherries | Ashley Drive | Bradbury House |
| Ridley Manor | Bury Lodge | Brook House | Cotswold Cottage | |
| Apple Hill | Beaconsfield Heights | Kingfisher | ||
| Meadowside | Seeleys House | |||
| Sir Aubrey Ward | ||||
| White Lodge |