1. Primary Care Healthy Homes Service
ABMU Health Board Lead: Zoe Wallace
West Cluster Lead: Dr Romilly Rees
Bridgend County Care & Repair Lead: Rena Sweeney
Results:
Between May 2016 and March 2017 the service received 237 referrals. 96% of patients were aged 75 and over. 93% of patients suffered from a long term chronic condition. 51% were identified as known fallers.
£211, has been raised in welfare benefits for patients referred to the service
Welsh Government grant funding has been used to install 12 boilers at a cost of £51, for patients in the West Cluster.
An Audit of 6 patients has identified on average a 41% reduction in attendance at Portway Surgery post intervention
The caseworker and occupational therapist undertook a range of interventions including, healthy homes assessments, prescription of aids & home adaptations, benefits checks and grant applications, falls assessments and signposting to a wide range of local services/organisations.
Feedback from patients:
“So good to have a service which has made me feel safe”
“Being able to have a heating system installed has taken away the worry of how to keep warm in winter”
“This service has changed my life for the better”
Feedback from the GP practices
“the real benefit for patients is receiving timely advice and practical solutions to their problems” GP
“The service has helped cut down on patients who require frequent calls” Practice Manager
Conclusion:
Bridgend County Care and Repair is an established third sector organisation which has delivered a high quality professional service in collaboration with the General Practices in the West Cluster for the last year. The service has already demonstrated the value of proactive housing related support within General Practice and feedback from both patients and GP practice staff has been extremely positive. In light of this success, the West Cluster has agreed to fund the service for a further year which will enable us to refine and develop the service to ensure it is meeting the needs of the local population and reducing demand on general practice.
Introduction:
General Practice is under significant pressure and one factor that contributes to this is an increasing older population with multiple and complex health and social care needs. The added value that other professionals, including caseworkers and occupational therapists bring to General Practice is increasingly recognised as part of the solution to maintaining and improving patient care within our local communities.
The Primary Care Health Homes service delivers an alternative, proactive model of care that focuses on early intervention and prevention. A Caseworker and Occupational Therapist who are employed by Bridgend Care and Repair work together to provide patients with a holistic, housing focused service which offers practical solutions for the home environment, provision of aids and adaptations as well as practical advice and support to help them live more comfortably, safely and independently at home.
Methods:
The Caseworker and Occupational Therapist work across four GP practices in the West Cluster in Bridgend.
The Caseworker works proactively with the staff within the practices to identify patients and collect referrals, as well as liaising with GPs following home visits if necessary.
The Caseworker and Occupational Therapist provide a bespoke person centred service that includes comprehensive financial advice and assistance to older people with regard to housing repair, maintenance and/or adaptation work required to enable them to remain living independently and safely in their own homes.
Demonstrable benefits include:
To reduce demand on general practice by addressing and resolving underlying issues that are the root cause of multiple and regular contacts.
Proactively resolve health and social issues at an early stage, minimising crisis situations that may result in presentation/admission to hospital.
Reducing falls and accidental injury by improving safety and confidence of patients in their own homes.
Supporting patients to maximise their own potential, promoting self-management and independence at home and in the local community.
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Methods: Here
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Older people aged 60 and over who:
are socially inactive and/or isolated
Are known fallers
Are frail and identified as at risk of falling
Live in poor or inappropriate housing
Have sensory loss and are at risk of falling
Have been recently discharged from hospital and identified as ‘at risk’ of accidental injury in the home
Have suffered previous accidental injury and have been admitted to A&E and require safety modifications to eliminate further risk.
Referral Criteria
Results: Here
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Figure 1:
Outcomes for assessed patients
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Conclusion: Here
Acknowledgements: