Patients benefiting from new Clinical Care Coordinators based in GP surgeries.
People across North Kirklees, including the frail and elderly and those with long term conditions and complex health needs, are benefitting from a new service, commissioned by NHS North Kirklees Clinical Commissioning Group (CCG) and jointly delivered by the local GP Federation, Curo Health, and community healthcare provider Locala Community Partnerships.
Five Clinical Care Coordinators are working with health, social care and voluntary agencies to support people to stay in their own home or be looked after in an appropriate setting, rather than hospital. The service is benefitting vulnerable patients who have been identified as being at a high risk of hospital admission.
Clinical Care Coordinators are working closely with the Community Nursing Teams and support patients, their families and carers to better manage living with long term illnesses such as diabetes or chronic obstructive pulmonary disease (COPD), so patients are less likely to become unwell and need hospital treatment.
Clinical Care Coordinators are also helping to identify patients who need support to continue living at home and are working with organisations such as the council and the voluntary sector to help them access this support.
Dr Stuart Lawson, a local GP, said: “The Clinical Care Coordinators are improving services for patients and providing good care nearer home. They help to provide a more joined up, tailored service to enable the patient to receive the most appropriate care for them either within or near to their own homes. It will also support them to understand their conditions better so they can feel more confident in managing times when their condition becomes worse.”
Julie Maguire, Clinical Care Coordinator for Batley Health Centre, Wellington House Surgery and Kirkgate Surgery said: “The clinical care coordinator role offers a truly holistic approach to patient care. We are able to spend quality time with patients to proactively assess their current and potential future needs. Our clinical knowledge and awareness of social and voluntary agencies ensures our patients receive the best support from the most appropriate services.”
Patients previously said that they did not always understand their medications, why or how to take them. They commented that they had difficulty understanding why their conditions suddenly become worse and what they should do in those circumstances and so ended up seeking urgent support.
One patient reported “My Clinical Care Co-ordinator properly listens to me and always takes the time to explain clearly and thoroughly, and I trust her and I know what she says is right for me and I can really talk to her.”
The Clinical Care Coordinators are now fully qualified in their role and were presented with their certificates at the NHS North Kirklees CCG Nurses Forum on 17 November 2015.