Connect Sudbury – early evidence of success

Early evidence is showing that a new project is helping to better support care home residents and their families.

Last year on average 9.4 people per month were being admitted to hospital from three care homes in Sudbury and its surrounding area. In April and May 2015 put together only one person from each home was taken to hospital, thanks to a new model supporting the patients and their families.

Some 139 people living in care homes in west Suffolk also now have an individual and personalised emergency plan or advance care plan because of the model. That means everyone caring for an individual knows exactly what to do when there is an emergency.

The West Suffolk Care Home Model is a partnership between the NHS West Suffolk Clinical Commissioning Group (WSCCG), West Suffolk NHS Foundation Trust, St Nicholas Hospice, participating GP practices and care homes. The key to the model’s success are discussions with residents and their families to develop a personalised emergency plan for each individual, which is supported by skilled care home staff.

This is part of the larger project, Connect Sudbury, which has been developed because local people called for health and social care services to work together much more closely.  Connect Sudbury brings all this together under one umbrella – simpler, better use of joined up resources to help you to live an independent life, and take control of who is involved in your support and when.

​Welcoming this news, James Cartlidge, MP for South Suffolk, said: “These are really early signs that Connect Sudbury is seeing a positive impact. Many people in Sudbury may not fully understand exactly what the Connect project means in practice, aside from bringing a lot of health-related bodies together into closer working. As far as I am concerned, one of the most tangible outcomes we should ultimately see from successful integration of services through the Connect initiative is reduced pressure on A&E as more care is provided closer to home.

“The reduced admissions statistics so far from this new Care Home Model are very promising and indicate precisely this outcome is being achieved – fewer admissions, with more appropriate care. Not only is this absolutely right for the people in care homes, but also it will help make sure that resources for those who do need to be in hospital beds are there”.

Sue Smith, West Suffolk NHS Foundation Trust care home clinical support manager, said: “I’ve been overwhelmed by the positive response when speaking to residents and their families. They are eager to have a planned conversation about emergency care. The majority of residents and family prefer to receive emergency care in the comfortable surroundings of their home by skilled and supportive care home staff. The model aims to meet individual’s personal choice, as well reduce unwanted hospital stays, which are a major cause of stress and upheaval for residents.”

​Pippa Wilding, St Nicholas Hospice Care Head of Education, said: “We are delighted Connect Sudbury is making such a difference. The Hospice works closely with care homes delivering training, offering guidance and support. Our aim is to ensure everybody has the very best experience in the last chapters of their life, Connect Sudbury will undoubtedly continue to support this objective.”

​Discussions with residents and their families about the type of urgent and end of life care they would like to receive are central to the model. The discussions give residents and their families time to explore options and create their own individual care and support plan, which sets out the care and treatment they and their family have chosen in the event of an urgent care need. It gives peace of mind to residents and their families, by ensuring each resident’s wishes are met, as well as giving staff, and other health professionals, clear directions about choices made.

Nationally 70% of those people who nearing the end of their lives want to die in familiar surroundings, whether that is home or residential home, yet less than 20% of those who make that choice do so. In fact more than 50% of people die in hospital.

Care home staff has been given extra training to assess a resident and identify whether their health is deteriorating. This assessment method is based on internationally recognised health frameworks and takes into account the physical, medical and mental health of the resident, such as whether they are suffering the onset of confusion, are becoming more frail or less mobile.

A regular assessment means that health issues can be identified and responded to sooner. Currently, the majority of residents, who have an individual care and support plan, choose to be managed in the community by their GP in order to avoid any unwanted hospital stay. The assessment also means that, if necessary, the resident, their family and GP, can begin timely End of Life planning, choosing the treatment they would like to receive and where they would prefer to be cared for in their latter stages of life.

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