Team Up including Ageing Well

Team Up Derbyshire is creating one team across health and social care in Derby and Derbyshire who see all the people in a neighbourhood who are currently unable to leave home without support.

This team is not a new or ‘add on’ service – it is a teaming up of existing services and the creation of additional capacity – with general practice, community care, mental health care, adult social care and the voluntary and community sector all working together and with their local communities.

The team provides care for people at home, avoiding the need for them to have to go to hospital wherever possible. The team provides both preventative care – anticipating health issues before they occur – and reactive/urgent care as and when required.

This means that person-centred care services are being provided at the right time, in the right place, by the right person. This approach is better both for the individual and the health and care system, making best use of available funds and resources.

The programme is being advanced by primary care networks (groups of GP practices working together) across Derby and Derbyshire, local health and care organisations (such as Derbyshire Community Health Services and local authorities) and the local place alliances (representatives of organisations in an area).

Team Up is encouraging new ways of working among colleagues: helping better integrate social care services with health, taking on existing services and expanding others, opening up access to some services and exploring opportunities to deliver some services differently.

A core offer of Team Up is the urgent community response service. This provides crisis response care within two hours of referral and reablement care (support to help people live at home) within two days of referral.

There are four components of this urgent community response service. These are:

1. Home visiting services – whereby people are being visited at home by a range of different health and care professionals – overseen by the primary care networks
2. Rapid response nursing and therapy services – provided by Derbyshire Community Health Services
3. Adult social care rapid response services – provided by local authorities and increasingly being integrated with NHS services
4. Falls prevention and falls recovery services – which are being expanded across the city and county under Team Up.

Linked in with this, Team Up is overseeing the enhanced health in care homes programme, which includes everything from support for developing workforce skills to digital IT projects, ensuring that care home staff are better able to look after their residents.

In addition, Team Up is progressing the anticipatory care programme, which is helping identify and respond to the needs of people before their health and care needs escalate, ensuring they can be looked after at home wherever possible, avoiding the need to go to hospital.

In the future, it is likely that more initiatives such as these will fall under the Team Up banner, bringing an even more joined up approach to delivering care.

For further information about the programme management of Team Up Derbyshire and Ageing Well, please contact Helen Baxter, Deputy Ageing Well Programme Manager, helen.baxter@nhs.net

For clinical advice/referral enquiries, please contact your GP Practice who will be able to put you in contact with the team in your area.

An introduction to Team Up Derbyshire

Team Up Derbyshire has produced a flyer to provide an introduction to the work of Team Up and the Ageing Well programme. It sets out the national and local context in which this work is happening, the key priorities and the service areas where improvements are being progressed.

Team Up Derbyshire Flyer

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The need to improve care for older people

People in England can now expect to live for longer than ever before – but these extra years of life are not always spent in good health, with many people developing conditions that reduce their independence and quality of life. The health and care sector has a key role to play in helping older people manage these long-term conditions, making sure they receive the right kind of support to help them live as well as possible. The NHS Long Term Plan (January 2019) set out a vision to give people greater control over the care they receive, with more care and support being offered in or close to people’s homes, rather than in hospital.

The national Ageing Well programme is a requirement of the NHS Long Term Plan and concerns how the population is looked after in the community. There is no age criteria although the vast majority of community resources are used to care for and support the moderate and severely frail population, of which there are approximately 30,000 in Derbyshire. The moderately and severely frail population in Derbyshire had 96,605 hospital bed days (in 2019-20) – the equivalent of about 10 wards. This figure is only predicted to increase in the future.

Programme objectives

Team Up Derbyshire’s objectives are to:

• Promote a multi-disciplinary team approach where professionals from the NHS and social care work with their communities in an integrated way, to provide tailored support that helps people live well and independently at home for longer 
• Ensure that the care and support people receive is based on their wishes, preferences and aspirations, particularly towards the end of their lives 
• Offer more support for people who look after family members, partners or friends because of their illness, frailty or disability 
• Develop more rapid community response teams, to support older people with health issues before they need hospital treatment and help those leaving hospital to return and recover at home 
• Offer more NHS support in care homes, including making sure there are strong links between care homes, local general practices and community services.

Team Up Derbyshire includes a new approach to providing a home visiting service for patients, reducing the need for emergency admissions, and relieving GP workload. It brings together step-up support (when an individual’s care needs escalate) and discharge pathways (ensuring that there are suitable options in place to allow people to leave hospital when appropriate to do so).

Team Up Derbyshire also incorporates three key initiatives of the national Ageing Well programme. These are: community urgent response (providing crisis response and reablement care), enhancing health in care homes (providing comprehensive support to care homes and their residents), and anticipatory care (working proactively with patients to maintain or improve health and wellbeing).

Acute home visiting service

An acute home visiting service is a responsive and effective home visiting service for patients, providing person-centred care, timely assessment and support for vulnerable patients. As well as being designed to help prevent hospital admissions, the acute home visiting service is set to improve the patient experience and lead to a better use of resources.

Housebound patients (in residential care or their own homes) are at higher risk of deteriorating health and hospital admissions. For GPs, home visits have to be fitted in around other surgery commitments, and smaller GP practices, in particular, can struggle to meet on-the-day peaks in demand for home visits. This has previously meant that patients unable to attend their surgery could experience a delayed holistic assessment of their needs.

Responsibility for providing the service will be across a larger footprint than a single GP practice. New approaches are now being explored in areas such as Erewash, Derby and Chesterfield. In the city and county, the aim is to provide an acute home visiting service which makes better use of the workforce, with visits being provided by a range of different professionals according to patient need. This will increasingly see nurses, therapists, paramedics or social care practitioners carry out home visits. 

While GPs will still visit people at home under this approach, their role will increasingly be one of overseeing patient care, supporting other members of the team. In this way, a range of professionals will provide the care that is most appropriate, working together as a team.

Urgent community response (Ageing well)

The urgent community response service aims to support people with complex needs to live safely in their communities, through co-ordinated and responsive care, reducing the need for unnecessary admissions to hospital and long-term care.

The urgent community response service is set to provide crisis response care within two hours of referral and reablement care within two days of referral. 

A crisis response service is a community-based service, typically provided by a multi-skilled team to people in their home with an urgent care need. Reablement care is a community-based service, typically provided by a multi-skilled team to maximise independence, and involves an assessment and intervention(s) to achieve goals set with the person. This is the active process of an individual regaining the skills, confidence and independence to enable them to do things for themselves, rather than having things done for them. 

The current response to people in their own home who have an urgent need is largely via the ambulance service or general practice. This approach is flawed because it is delivered by a single clinician who can feel time-pressured and unsupported or that they are alone in problem solving. This can also result in reliance on hospitals as a place of safety rather than reserving them for specialist provision of healthcare. It is proposed to develop community multi-disciplinary teams to be the default first line urgent community response. This will see a response not only to the presenting issue and the need to ‘make safe’ but also with an explicit remit to identify and address underlying issues.

Falls Prevention

At the heart of our commitment to ageing well is the need to reduce the risk of falls among our communities. Falls prevention work is essential because it identifies areas in people’s lives that can be improved through simple interventions. These include their physical environment, their health and fitness, and their strength and balance. If we can support patients to avoid having a fall, we can avoid so much more.

Our new ‘Falls Prevention’ pathway, Ask, Assess, Act, is created to support everyone—from healthcare professionals to family members—who interact with individuals at risk of falling.

This resource offers straightforward, actionable steps to identify fall risks, assess individual needs, and implement effective prevention strategies. By increasing awareness and encouraging proactive measures, we aim to create a safer environment that enhances mobility and wellbeing for our ageing population.

DRAFT Derby and Derbyshire Falls Prevention Pathway

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