Case Study – Newcastle Extensivist Service

The challenge

To deliver a consistent and coherent approach to elderly care in Newcastle-under-Lyme.

Who’s involved

  • Northern New Care Models Team
  • Fylde Coast Extensivist Team
  • Primary Care – GPs, Practice Nurses and Elderly Care Facilitators
  • NSCHT – Community Psychiatric Nurses, Consultant Psychiatrists
  • SSOTP – District Nurses, Therapists, Social Workers
  • UHNM- consultant geriatricians and high intensity user group
  • Clinical Commissioning Group

What we’re doing

Developing an elderly care strategy that considers all levels of need.

Delivering a consistent approach to the assessment, identification and coding of frailty at practice level.

Developing a whole population approach using practice based Elderly Care Facilitators (ECF) for proactive identification of needs.

Developing a community-based multidimensional, interdisciplinary assessment on a cohort of highest needs for the elderly to allow the planning and implementation of individualised, holistic plans for treatment, intervention, support and follow up.

Expected outcomes

Improved functional outcomes avoiding significant changes in life such as admission to a care home or hospitalisation.

Rationalised health and social care system, managing multi morbidly and polypharmacy enabling the local system to have a more effective urgent care response to individual’s needs, including reducing bed days in the case of required admission.

Empowered patients and carers who better understand their care needs will improve their level of activation/ engagement and their ability to self-manage – this in turn improves patient satisfaction and allows them to utilise the local health and care systems more effectively.