Care Home Team (Single Point of Access)

We have various clinical roles with in the PCN that deliver enhanced health care within Care Homes. We have Paramedics, Trainee ACP’s, Advanced Nurse Practitioners and Physician Associates. 
The enhanced health in care homes moves away from traditional reactive models of care delivery towards proactive care that is centred on the needs of individual residents, their families and care home staff. Such care can only be achieved through a whole-system, collaborative approach.

People living in care homes should expect the same level of support as if they were living in their own home. This can only be achieved through collaborative working between health, social care, Voluntary, Community, and Social Enterprise (VCSE) sector and care home partners. 

Personalised care

• Putting the needs of the person at the centre through “what matters to you” conversations and personalised care and support planning processes.
• Supporting people to talk about the outcomes that matter most to them; and
  encouraging and enabling them to take on as much responsibility as they
  want to manage their own care, health and wellbeing.
• Supporting carers and families and recognising their needs, as well as those of the individual care home resident, and acknowledging them all as experts in their own care and lives.

Co-production

• Working and integrating with local government, the community and the VCSE and independent care homes sectors to co-design and co-deliver the model of care as equal partners.
• Acknowledging the value of the care home sector in working alongside the NHS and the significant level of healthcare that is delivered in care homes by social care staff.
• Adopting a whole-system approach, breaking down the organisational barriers between health, social care, and the VCSE sector.

Quality

• A focus on quality as the driving factor for change.
• Using clinical evidence to drive and sustain change. 

Social Prescribing Team

We have several Social Prescribers who tackle the non-medical problems that can affect your health and wellbeing. They can connect people to the information, services, organisations and support to help improve their health and wellbeing.

Many things affect our health and wellbeing that can’t be treated by doctors or medicine alone. These include issues such as loneliness, stress, money worries or poor housing. They can help people to find the support they need, based on their unique situation.

Our practical and emotional support has helped hundreds of people increase their confidence and improve their health and wellbeing by connecting people with the right support. Our service is open to anyone aged 16 years and over who are registered with one of our 5 PCN practices. 

Social Prescribing Link Worker (Young People)

For our younger patients, we also have a Social Prescribing Link Worker whose aim is to help to improve the understanding of the challenges young people are facing. They are able to help them to access support groups, activities and other services, with the aim of meeting their practical, social and emotional needs which often impact health and wellbeing. 

Young Persons Social Prescribing Link Workers can support you by:

• Listening to what matters to you and providing you with private and confidential and non-judgemental space in which to discuss the challenges you are facing or goals for the future
• Helping you to create a plan with some practical information, advice, and guidance around the options available to you to help you to improve your circumstances.
• Being available to have regular appointments in which you can talk about your progress and how you feel
• Connecting you with relevant services and support
• Helping you develop a ‘care plan’ which is your well-being toolkit

MSK Practitioners

We have MSK practitioners who deal with Musculoskeletal (MSK) related health issues, which are the most common cause of frequent and repeat GP appointments. These can account for between 10 and 20 per cent of overall appointments and the majority of them could be dealt with by a physiotherapist without any need to see the GP. These appointments can be booked directly through the care navigators at each of our PCN surgeries, without needing to see a GP first.

Care co-ordinators

We have a team of PCN Care Co-ordinators who work closely with the GPs and other primary care professionals within the Primary Care Network (PCN). Their role is to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers and ensuring that their changing needs are addressed. They provide a more joined-up and coordinated care journey for patients, instead of each encounter with services being seen as a single, unconnected ‘episode’ of care.

Care co-ordinators act as a single point of contact for patients to navigate the health and care system.