Enhanced Health in Care Homes

Arc Bucks Primary Care Network provides care services for local care homes under the NHS Network Contract Directed Enhance Service (DES). We are comprised of 6 general practices and work across 2 hubs, based out of Marlow and Beaconsfield respectively. 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 conduct weekly Ward Round reviews at all the 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.

Immedicare: 

To ensure the best standard of care for all residents, all care homes in Buckinghamshire are provided with 24/7 direct access to a highly trained clinical team. Any day, nighttime or daytime, the care home staff can use this telemedicine service as a first port of call to discuss any clinical concerns that may arise.

 

Care Homes under Arc Bucks PCN: 

 

Marlow Medical Group

Cliveden Manor

Ridley Manor

Apple Hill

Meadowside

Sir Aubrey Ward

White Lodge

 

The Simpson Centre

Adele House

Bury Lodge

Beaconsfield Heights

Seeleys House

 

Wooburn Green & Bourne End Medical Centre

Cherries

Brook House

Kingfisher

 

Highfield Surgery

Ashley Drive

Cotswold Cottage

 

Millbarn Medical Centre

Bradbury House