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Health and social care team is reducing the need for west Suffolk patients to be submitted to hospital




A partnership service that has allowed more than 900 people in west Suffolk to be cared for at home - 57 of them in the Haverhill area - rather than admitted to hospital, has been extended into spring.

A holistic health and social care team of ambulance and community staff uses a rapid intervention vehicle (RIV) to visit and assess patients in their own home, helping to maintain patients’ independence and reduce the pressure on hospital services.

The service is jointly provided by the East of England Ambulance Service Trust (EEAST) and the West Suffolk NHS Foundation Trust (WSFT), in collaboration with the West Suffolk Clinical Commissioning Group (WSCCG) as part of the West Suffolk Alliance – a commitment to better joint-working between healthcare providers and beyond for the benefit of local people.

Teams from WSFT and EEAST unite to support patients in their own home. Contributed picture
Teams from WSFT and EEAST unite to support patients in their own home. Contributed picture

Most of the patients the service cares for are elderly, frail and housebound; may have had a fall or developed an infection, and are unable to go to their GP. The RIV can visit between five to six patients a day, depending on the travel involved.

The WSFT provides staff from the early intervention team (EIT), and team lead Gareth Blissett explained how the partners come together to respond to a range of referrers in the west of the county, including 999 calls.

He said: “We use an ambulance service rapid response vehicle with a specialist paramedic on board who can prescribe medication; and from EIT, a nurse, therapist, social worker or assistant practitioner.

"We assess the patient in their home; provide medical treatment and assessment such as wound care, medication to treat an infection and therapy to improve their mobility.

"The team has social care practitioners and emergency care within the team, so is able to organise support and makes onward referrals on to community nurses, therapists, our equipment service, and the voluntary sector.”

Gareth continued: “The aim is to give the patient the support and care they need to be able to stay at home after our visit; and organise everything they need to maintain their independence and experience the best quality of life possible.”

Between October 2018 when the service started, to early December 2019, the RIV team received 1,157 referrals, with November 2019 the busiest month. Consistently, 79% of people cared for by the service are able to remain in their own home, with a comprehensive package of care designed to meet their individual need.

In response to increased demand, the rapid intervention vehicle is now operating 12 hours a day, seven days a week until the end of March.

The EIT team operates 24/7, but Gareth explained that the RIV is an enhancement of that service and allows joined-up care to be wrapped around the patient: “We can get there quickly, offer an early, comprehensive assessment and so have more time to put care in place through improved communication with all our partners.”

Case studies show how the team treats the whole person, taking into account their home life, for example prescribing medication for a patient to overcome infection; arranging equipment and overnight care to keep them safe in the days after discharge; organising therapy to improve mobility; and voluntary support to help their spouse cope, or help with domestic tasks.

One person who had been confined to a sofa for 12 days was provided with equipment and a package of care, treatment for wounds, and referral to community nurses and therapists so they could regain their mobility.

After four days, the patient required no further care.

Dawn Whelan, EEAST’s sector business and partnerships lead, said that paramedics and emergency care practitioners are increasingly working away from ambulances with partners in the healthcare system.

She said: “The RIV is an opportunity for EEAST colleagues to experience other clinical settings, helping us to respond to both 999 calls and primary care referrals. This project has provided learning opportunities for our people, improving both recruitment and staff retention.

“Having a vehicle like this is not only good for these patients as it gives them the help and care they need in their own home, but means other ambulance resources can be focused on attending people with potentially life-threatening conditions.”

Michelle Glass, associate director of operations for community and integrated services said: “This is making a positive difference to the care of many of our local west Suffolk residents, and reducing the demand on ambulance and acute hospital services.

"By visiting people where they live, we can assess their medical, physical and mental health and start to arrange what they need to stay in their home.”

Nicole Smith, senior transformation lead – integrated care, CCG said: “These extended hours, which are in place until March, will continue to help over the winter period, supporting people to remain well and in their home.

"The RIV service is a great example of how the West Suffolk Alliance can work across the whole system, strengthening the support for people where they live."