Primary care team: Enhanced nursing helps GPs reach out to vulnerable patients

A nursing service set up in north London has helped GPs improve management of their most vulnerable patients, says Harrow GP Dr Amol Kelshiker.

As the UK population ages, GPs face questions about how we can effectively manage elderly housebound patients living with one or more long-term conditions.

GPs in Harrow are reaching out to patients through an ‘enhanced nursing’ team which extends our clinical influence by proxy.

The nurses help identify the most vulnerable patients who rely heavily on primary and secondary care, with above average A&E attendance and hospital admissions.

This is done through case note reviews and individuals flagged up through our EMIS and QRisk systems.

Long-term conditions

The 28-strong team focus on patients aged over 65 with one or more long-term conditions and currently has a collective caseload of more than 700 patients. The average patient is 82 years old.

Their primary role is to minimise attendances, co-ordinate more holistic care from relevant agencies and support greater self-management.

This starts with a case management review before progressing to home visits, a health assessment, and co-ordinating various agencies’ efforts before the patient is ‘discharged’ after four to six weeks.

The home visits offer a window into social and economic circumstances that may be indirectly affecting an individual’s health as well as helping us see things from their perspective.

A visual assessment of patients’ homes is often as revealing as a physical examination telling the nurse how the patient is coping and what sort of additional support they need.

Enhanced nursing team

Our enhanced nurses are advanced practitioners in one or more fields but their job description could easily include part-time detective, troubleshooter and bridge builder.

Their day to-day work can encompass anything from checking blood sugar levels, replacing catheters and dressing wounds to medicine reviews, arranging social care, and provision of end-of-life care.

They also co-ordinate the involvement of various agencies, such as social services and community and voluntary groups.

The majority of these patients need support from social services but aren’t getting it. It would be unfair to criticise the local authority because the problem is usually patients being unaware of their entitlements or being scared to ask for help from social services.

To address this we have built a good relationship with the council’s social services department, flagging up individuals who need help.

It’s worth noting that some elderly people are wary about letting social services into their lives and the nurses help explain what social services does, how it can help and the fact that they do means test individuals to see if they have to contribute to their care.

Some might argue that nurses have enough on their plate without taking on additional social responsibilities but GP surgeries often have to deal with the fallout of the same problem further down the line.

Designated GPs like me work closely with the enhanced nurses and meet on a weekly basis to discuss cases, provide advice and support and, where necessary, get more involved.

We recently approved a second year of funding for the enhanced nursing service and feedback has been positive from both patients and GPs.

We all know the value of a familiar and reassuring face and the understanding and continuity of care that brings.

The additional investment isn’t that great in the scheme of things - the service cost £627,000 in its first year - and by helping other people we are ultimately helping ourselves by having happier and more independent patients.

Key facts about the Harrow enhanced nursing service
  • Harrow currently employs 28 enhanced practice nurses (EPNs)
  • EPN duties vary from post-discharge consultations to general review of chronic conditions, including medication reviews and flu vaccination
  • The service has more than 700 patients on its books
  • The EPN team collectively works nearly 400 hours a week
  • The average patient is 82 years old
  • Most patients are visited in their homes with only a small number receiving telephone consultations
  • EPNs see patients following discharge from hospital, from GP referrals due to high risk of hospital admission and/or practice intelligence.
  • The majority of patients have severe social problems and need assistance from Social Services

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