Patients with complex and long term health conditions are able to get extra support on the ‘proactive care pathway’. GPs identify from their patient lists, those who are at more risk of going into crisis and ending up in hospital. A community matron does an initial assessment and then a package of care is put in place and delivered by a multidisciplinary team made up of health, social and voluntary sector staff. The purpose is to help keep patients well, enhance their quality of life and reduce the risk of them falling into crisis and ending up as an emergency admission to hospital.
As of November 2019, there has been a 26% reduction in urgent hospital admissions & 22% reduction in un-elective inpatient admissions for those patients who are 13 weeks post their multi-disciplinary team assessment on the proactive care pathway (2,966 patients). This represents an estimated Emergency Department cost save of £81k (443 fewer contacts) and Un-elective Inpatient Admission cost save of £267k (259 fewer contacts) across the same period.
The Bromley @home service has been piloted to create a more integrated, community based system that prevents the need for hospital attendance and admission. The pilot was successful in increasing the number of patients supported by community healthcare services after discharge from hospital. The learning from the pilot is being taken forward through the streamlining of community pathways out of hospital to provide a single point of access for patients leaving hospital who require health and care support.
Improved GP services in residential care
We have created a new general practice specifically for people living in Bromley’s care homes. Recognising that people in care homes have a higher rate of hospital attendances and admissions, and more longer term conditions and medications needs, a GP practice service has been commissioned that will provide both proactive (ward round) and reactive (urgent) care to the 1,800 people living across Bromley’s 40+ homes. The service will use doctors, nurses and pharmacists to work with the care homes as well as the patients and their families to avoid unnecessary hospitalisation and improve the quality, access and experience of primary care for these patients.
The service provides:
There have been other improvements including:
One Bromley schemes will be delivered via a phased approach. Phase 1 will focus on urgent and emergency care and management of winter pressures.
Key schemes in phase 1:
Key schemes in phase 2:
An update on One Bromley was discussed at the Bromley Health and Wellbeing Committee on 21 November 2019. You can read the paper here.