Photo Credit: Fizkes

The following is a summary of “A Long Way from Frome: Improving Connections between Patients, Local Services and Communities to Reduce Emergency Admissions,” published in the August 2024 issue of Primary Care by Withers et al.

Low socio-economic status is a significant determinant of poor health outcomes, often exacerbated by the fragmentation between health and social care services. This disconnect creates a pressing need for innovative models that better integrate these services. This study aimed to enhance the connections between patients, local services, and their communities within a primary care cluster characterized by high levels of deprivation. The goal was to reduce unscheduled hospital admissions by fostering a more cohesive support network for patients with complex medical and social needs. The study was conducted within a primary care cluster comprising 11 general practices, collectively serving over 74,000 individuals.

A multidisciplinary team (MDT) was established, bringing together representatives from healthcare, local government, and the third sector. This team focused on providing comprehensive support for individuals with multifaceted needs. A discharge liaison hub was created to proactively contact patients after hospital discharge, offering tailored support to ease their transition into the community. In parallel, cluster pharmacists took the lead in conducting thorough medication reviews to optimize treatment regimens. Additionally, Wellbeing Connectors were commissioned to bridge the gap between patients and local wellbeing and social resources, ensuring they had access to the support they needed. Advance Care Planning was also implemented to facilitate personalized decision-making, aligning care with patient’s values and preferences.

The results of this integrated approach were significant. There was a marked decrease in unscheduled admissions among the over-75 age group, translating to over 800 avoided monthly referrals to assessment units within the cluster. Since the inception of the MDT, more than 2,500 patients have been reviewed, leading to referrals to social prescribing groups, physiotherapy, and mental health services. Notably, patients whose cases were discussed by the MDT were 20% less likely to contact their GP afterward, reducing the need for further primary care interventions. Furthermore, 80% of patients who engaged with Wellbeing Connectors reported improved well-being.

The integration efforts benefited patients and positively impacted the healthcare staff, who reported a better ability to meet patient needs and increased job satisfaction.

In conclusion, the enhanced integration between health, social care, and third-sector services within this primary care cluster substantially reduced hospital admissions, improved patient well-being, and increased job satisfaction among healthcare providers. This model demonstrates the potential for integrated care approaches to effectively address the complex needs of deprived communities.

Source: bmcprimcare.biomedcentral.com/articles/10.1186/s12875-024-02557-4