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First “vanguard” site in UK delivering integrated care

As government in the UK moves social care nearer to health care provision our National Health Service (NHS) trusts are looking at broader programs and ways to deliver holistic interventions for patients. Salford Royal NHS Foundation Trust (Salford, Greater Manchester, United Kingdom) is part of a local partnership, Salford Together, which is bringing together health care, home care, mental health and community nursing, hospital, and social services into a new, unified model of care.

3 examples of blended clinical and social interventions

NHS granted “vanguard” status to the Salford Together collaboration to encourage innovative approaches and new models of care. We’re working to break down barriers to blend social and health services as the most effective way to meet our patients’ needs. Here are just a few examples:

1) Safer discharges for elderly patients

Older patients who were discharged late in the day were more likely to be readmitted than those discharged earlier in the day. To offset these disadvantages, clinicians created a set of social interventions that could help aid in a more successful transition from hospital to home. A great example of this is us using the third sector or charitable organisations to support older people in returning to home after a hospital stay.

After a holistic assessment of needs, clinicians can assign chaperones to take patients home, stock their refrigerators with food, reassess the home environment for safety issues and settle them in their own beds for that first night home. Addressing these social care needs can lead to better health outcomes.

2) More coordinated care for palliative patients

Developing an end-of-life care plan enables patients to age well and express how they wish to live their final months, weeks or days. Patients can express their preferences for place of death, family members to notify, spiritual considerations and more.

Because a care team might include members from social services, ambulance trust, accident and emergency, and outpatient sites, it’s important these plans are well documented and able to be shared. Effective care coordination during end of life puts patients in control and helps ensure they receive dignified, respectful care that is in accordance with their wishes.

3) Richer clinical information for diabetic patients

One of the trends that can enrich information for patients with chronic disease is to blend patient-collected data with clinical data. By incorporating data from the patient’s home and environment, such as pain scores on a day-to-day basis, clinicians can build a more accurate picture of trends – either positive or negative – that impact a patient’s health.

Richer data sets enable patients and clinicians to have better conversations centered around care options to manage chronic pain or other aspects of the disease. This may be medical data but increasingly we are interested in the lifestyle data of the patient in order to understand the context in relation to their condition.

The gravitational pull of the electronic patient record (EPR*)

A high-performing EPR is imperative to identifying and delivering appropriate services for patients. Our efforts revolve around the complete and total use of EPR data, enabling it to be the central gravitational pull for everything we do.

Salford Royal is an early pioneer in blending information – whether health, patient-collected or clinician-entered – and brings it into actionable information so clinicians are able to prepare the best care plan possible for every patient.

The benefits of blended data go beyond individual patients, and also can deliver improved patient outcomes for identified populations. Allscripts Sunrise™ is a central data source for the many research studies we conduct at Salford Royal, and patients who consent to participate are also contributing to improved health care for the future.

As one of the first vanguard sites in the UK to advance this unified care model, Salford Royal continues to measure the efficacy for patients and populations. We have an exciting journey ahead.

 

*Editor’s Note: Electronic Patient Record (EPR) is another term for Electronic Medical Record (EMR) or Electronic Health Record (EHR).

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