Weymouth Elderly Care Service
An NHS ward round approach by a core team caring for people in Care and Nursing Homes, and for housebound patients in the locality. The team comprises Drs Godfrey and a team of nurses and nurse practitioners. This team works in an integrated fashion with the wider MDT which currently exists in the locality offering a proactive service, reducing non elective or emergency admissions, better management of long term conditions and more co-ordinated care planning for end of life. This team links back to practices in support of the current MDT working arrangements
A key function is early identification of deteriorating patients or early diagnosis which will enable the core team and existing health and social care teams to set in place early intervention. We anticipate that the positive effect of this will be demonstrated through reduced emergency admission, reduced permanent admissions to care and residential homes, and people able to remain in their own homes or place of residence for as long as possible.
Pilots elsewhere in the country have shown that up to 20% of people can be supported in their own home rather than admission to home care through identification of Mental Health illness, loneliness and social isolation, assessment of compliance with medications, assessment of risk of falls and nutritional status.