Improvements being delivered through One Bromley

Proactive Care  

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.

• Between April 2017 and Aug 2018, 2,470 patients have been referred onto the proactive care pathway.
• From the 1,808 patients who have been on the pathway for 13 weeks or more, there has been a 27% reduction from those patients in hospital attendances.  

Bromley @Home

The Bromley @Home Service provides a range of services to support patients in their own home, by either preventing unnecessary admission to hospital, or by helping them return home sooner between 8am and 8pm Monday to Sunday. 

At March 2019, the service has seen 256 referrals with only 2% of patients being admitted to hospital. We expect this to improve as we introduce more specialist input into the team. The service has made a significant cost saving to the wider healthcare system and improved the care for these patients. 

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 will provide:

• Regular weekly/biweekly visits to all homes
• A comprehensive medical assessment of each resident upon admission to the care home and follow up medical assessments at least twice a year
• A comprehensive medical assessment and medicines review following any patient who has been admitted to then discharged from hospital
• A medicines review at least once a year.
• Urgent same day visits.
• Close working with care home staff and other health and social care services.
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Planned programmes

Our current focus is on improving the urgent and emergency are systems across Bromley so that services can work in a more joined up way to provide urgent care and reduce emergency hospital admissions.  

Our planned programmes are as follows: