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BORTH INTEGRATED HEALTH AND CARE COMMUNITY SERVICES

Dr Sue Fish – GP Partner Borth Surgery – Project Lead

Claire Bryant – Advanced Nurse Practitioner and Clinical Care Co-Ordinator

Jacqui Jones Browne – Practice and Project Manager

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Project Background

Borth and surrounding population
Number of multi-disciplinary teams (MDTs) working in silos
General Practice was not integrated within the MDTs
Bureaucratic referral processes
Very little patient centred integrated working
All parts of the system post pandemic under extreme pressure

BORTH

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Borth Integrated Health and Care Community Services Project

The Borth Community Interest and Advisory Group for Health and Care was established in April 2021
In order to improve the delivery of planned care stakeholder organisations needed to increase their capacity
Whole system transformation was required in the delivery of health and care community services through Patient Centred Multi-agency Team (MAT) Working
Increased use of Third Sector Services required

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Project Approach

Clinical Care Co-Ordinator – Band 8A Advanced Nurse Practitioner employed in General Practice
Terms of reference agreed for meetings
Administrative support for MAT identified
Established weekly one hour long MAT meetings
Any member of the MAT could discuss any patient registered with Borth Surgery under their care
Roll out to second surgery January 2023

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Members of the MAT meeting

Clinical Care Co-Ordinator (Chair)
Administrator (Minute Taker)
GP
Borth Practice Nurse
Community Pharmacist
District Nursing Team
Community Therapy Representation
Community Dietician
Older Person’s Mental Health Team
Bronglais Hospital Frailty Team

Bronglais Hospital Flow Team
Palliative Care Team
Social Worker/Assistant
Reablement
Red Cross
Community Connector/Carers Service
Bronglais Hospital Frailty Team
Bronglais Hospital Flow Team
Borth Community Hub

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Number of Patients Discussed and Referral Source

Total Number of Patients 104

Patients not in hospital 50

Primary Care 9
Hospital out-patient referrals 5
Palliative Care 12
Referrals to Porth Gofal 9
Frail elderly in person 11
Mental Health 2
Cartref Tregerddan 6

Patients admitted to hospital 54

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��Feedback from people attending MAT meetings in person:

People listened to what was important to me

I found attending the MAT a very positive experience

It is very reassuring to know that there are so many people and services available to me that I did not know about before the meeting

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In Person Mental Wellbeing Scores

��

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Effect on GP Appointments– Frailty

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Ceredigion County Council

The Carers and Community Support Team

16 referrals – 15% of patients discussed at MAT

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Number of Patients Referred to 3^rd Sector

	Number Referred	Percentage of Patients Discussed	Number of Patients still engaged
Borth Community Hub	16	15%	12

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MAT Member Feedback

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�Effect on Length of Stay Borth Surgery

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�Effect on Length of Stay Tregaron Surgery

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Borth Surgery - Bed Days Saved

	Total Number of Bed Days	Total Number of Patients
June 21 – Feb 22	1881	133
June 22 – Feb 23	1328	173

Total number of bed days saved due to reduction in length of stay – 553

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��Further Evaluation

Planned admissions increased but the average LOS reduced by 37% - saving around 160 bed days

The conversion rate of ED attendances increased significantly

Of those people who died after contact with MAT – 38% died in hospital

Typically 52% of Hywel Dda residents die in hospital

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��Resources

Likely reduction in resource usage for IP spells is around £579k (fully absorbed) / £340k (releasable)

Likely increase in ED attendance resource cost is £38k

Project cost £60k

Net overall effect is therefore resource releasing – approx. £250k net benefit

Area	Cost per day / attendance
Fully absorbed cost – BGH general medical bed	£1,094
“Releasable” resource cost – BGH gen medical bed	£640
BGH ED attendance average cost	£314

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��

Barriers

Culture
Bureaucratic referral process
Silo working across organisations
Resource deficits/service gaps
IT systems
Funding silos

Enablers

Clinical Care Coordinator in Primary care
Relationships, trust, ‘can do’ attitude
Focus on person-centred care
Building on and establishing new networks

Reflections

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Conclusions

Through multi-agency team working facilitated by a clinical care co-ordinator based in general practice savings can be generated in cost and capacity in secondary care.
This increase in capacity will enable more planned care services to be delivered.
The benefits from the MAT model appear to be due to improved communication and reduced duplication between agencies.
Through increased referral to third sector services there is increased capacity generated in general practice to enable the primary care team to concentrate on patients with more complex care and deliver more planned patient care.
There has not been an increase in demand for social services care packages and there may have been a reduction.

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Contact Details

Email : Dr Sue Fish sue.fish@wales.nhs.uk

Claire Bryant Claire.M.Bryant@wales.nhs.uk

Jacqui Jones Browne Jacqui.JonesBrowne@wales.nhs.uk

Twitter: @DrSueFish