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proactive and preventative

Improve outcomes in population health and care

As an Integrated Care System, we want to put our residents at the heart of everything we do and build trust, underpinned by digital inclusion. Below you can find some of the work that has been happening to support this aim.


Supporting surge vaccination in Nuneaton

The vaccination programme is delivered through the collaboration of all partners across the whole of the Integrated Care System. 

When cases of a new variant of COVID -19 were found in Nuneaton, the vaccination programme was stepped up in co-ordination with community testing. Local GPs, the George Eliot Hospital and Coventry and Warwickshire Partnership Trust come together to help ramp up vaccination in the community. Using a “vaccination ambulance” we were able to take the jab directly to the wards where we knew the variant was spreading, supporting greater uptake and preventing further spread of the virus.

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Delivering integrated Musculoskeletal services in the community

Health services across Coventry came together to provide a new way of delivering care for patients with a wide range of musculoskeletal conditions. Musculoskeletal (MSK) conditions are those which affect the joints, bones and muscles, as well as include rarer autoimmune diseases and back pain.

The service brings GPs together with community and hospital services to improve access to MSK services and help patients better manage their conditions, shifting the focus from specialist, hospital–based care into community focused provision, with greater emphasis on prevention, self-management and holistic therapy-led interventions.

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Dene and Stour PCN Multidisciplinary Teams (MDTs)

The introduction of Multidisciplinary Teams (MDTs) in Dene and Stour PCN has increased the scope of support that GP practices can offer to patients. Three new roles have been created, Health and Wellbeing Coach, Social Prescriber, and Care Coordinator, and they offer a range of services including support with issues such as housing, homelessness, addiction, bereavement, and debt, that would have previously required referrals to external services.

Prior to the creation of these teams within GP practices, a GP would have to refer the patient to several other health professionals, which would mean multiple appointments in different locations and often patients were waiting longer to receive the care they needed.

Patients are already enjoying the benefits of these new roles, including quicker, more flexible, and more holistic treatment that has been improved by the sharing of knowledge and skills between the MDTs.

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Using frailty virtual wards to prevent hospital admissions

The introduction of frailty virtual wards in South Warwickshire has meant patients who would otherwise be admitted to hospital can now be treated at home whilst still receiving the care they need to recover.

The Urgent Community Response team can offer face-to-face support to a patient, while also speaking to a range of other healthcare professionals, such as consultants and GPs, using the virtual ward.

Patients benefit because they are able to remain close to their support networks and do not have to be admitted to hospital, which can be a stressful experience. There are also benefits to the health service as demand on the ambulance service and hospital capacity is reduced.

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Urgent Community response service: Keeping people out of hospital 

The Urgent Community Response service, based at South Warwickshire Foundation NHS Trust, provides urgent support seven days a week to help prevent hospital admissions. This service is for adults with certain conditions and particularly the elderly and frail. 

Mr Har Singh was one patient who has been referred to this service and his family have seen the benefits to this more personalised approach to care. 

When Mr Singh became ill, the Urgent Community Response team were able to keep him at home rather than admit him into hospital. 

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Warwickshire frailty service keeps half of patients at home after falls

An innovative, partnership approach to caring for the frail and elderly in Warwickshire has led to a frailty service that is keeping 50% patients at home after a fall, with just 3% having to return to hospital at a later date, down from 15%.

When paramedics visit someone whose had a fall, they can call a frailty phone for advice from frailty consultants and Advanced Care Practitioners (ACP). Every discharged patient over 75 is called by a nurse and to support the service, a partnership with Warwickshire Fire and Rescue means they are assessing the risk of slips, trips and falls and bringing food bags to patients’ homes, to prevent them going back to hospital.

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Using new technology to support patients with Covid-19 to remain safe at home

Research has shown that patients most at risk of becoming very unwell from coronavirus are best identified by their oxygen levels. To support patients with Covid-19 to remain in their homes while still being safely monitored, the Partnership worked collaboratively across GPs, hospitals, ICBs (Coventry & Rugby, Warwickshire North & South Warwickshire) and NHS volunteers to provide the ‘Covid Oximetry at Home Service’. The services are being delivered by South Warwickshire Federation and GP Alliance across Coventry and Warwickshire.

This self-monitoring model is part of a range of technology initiatives being developed by the NHS to provide better connected and more personalised care in people’s homes.

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South Warwickshire's Integrated Single Point of Access (iSPA)

South Warwickshire University NHS Foundation Trust (SWFT) have developed an Integrated Single Point of Access (iSPA) system, a telephone and email service where patients, carers and health professionals can refer to services.

The iSPA has evolved over the past 3 years and the team now take up to 10,000 calls a month and have also implemented a text messaging facility which has saved 2,000-3,000 outbound calls a month. In 2019 they were joined by the Integrated Care Coordination team (ICC) who clinically triage all of the community services who require an urgent or same day response.

These teams have been instrumental in supporting with the rollout of telehealth monitoring initiatives including MySense and DOCOBO, allowing us to reach service users in a new and innovative way – which has been vital during challenging periods such as the pandemic.

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Accelerating care for patients with a Community Diagnostic Centre

The Community Diagnostic Centre (CDC) welcomed its first patients on 15th August 2022 as part of the first phase of the CDC project.  

The centre, which will serve the Warwickshire North population, joins a network of over 90 CDCs already open across England together delivering over 1.5 million checks – including over 700,000 additional CT, MRI, ultrasound, endoscopy and ultrasound tests.

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Engaging with children in schools to promote healthy lifestyles and weight management

Engaging with children in Year 6 via local schools to promote healthy lifestyles and weight within the education setting. Uptake of the Change Makers services within these areas is low and the aim includes speaking to parents at schools within Nuneaton Central to understand their understanding of Change Makers and how the service could be improved to better meet needs.  

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The Back to Health volunteering model

The Back to Health volunteering model uses volunteering as a catalyst for closer integration of health and care systems between George Eliot Hospital and the local community. It proposes using volunteer intervention at five stages across the patient pathway to improve health and wellbeing, demonstrating the impact that well designed, impactful volunteering roles have on “Getting Well”, “Recovering Well”, “Living Well”, and “Waiting Well” in North Arden and Nuneaton Central & South.

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Population Health Management community engagement

Warwickshire North (WN) Place have undertaken community engagement work with the local population, aligned to our Population Health Management (PHM) approach and focused on WN’s chosen PHM cohort, in order to understand their experience of or barriers to accessing services currently offered in the area.

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Implementing Docobo Telehealth to support residents and staff in care homes 

The Warwickshire North (WN) Docobo Telehealth in Care Homes Project was initiated to support the Virtual Ward Round initiative already underway. Care Homes were offered the ability to capture health metrics, blood pressure, pulse, SaO2 and temperature, along with specifically designed question sets for their residents. 

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Reducing gynaecological waiting times using the Primary Care Gynaecology Service

The Primary Care Gynaecology Service has been established in order to reduce gynaecological waiting times for elective care. The service utilises the skills and experience of GPs in primary care and offers appointments for a range of gynaecological conditions and treatments to patients who otherwise would have to wait to be seen for a significant amount of time due to long waiting lists within secondary care.

Phase one of the service was extremely successful in allowing patients to access treatment sooner and 80% of identified patients already on a secondary care waiting list were offered care within primary care and successfully treated. The service has now moved to phase 2 and a new system of direct referrals is now live, enabling us to continue to provide an enhanced gynaecology service resulting in care closer to home for our patients and helping to reduce pressures on secondary care services.

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Centralisation of stroke services across Coventry and Warwickshire

The new centralised stroke pathway was launched in Coventry and Warwickshire on 1st September 2022. The change to the pathway came following an analysis of local stroke services that identified unwanted variation in the range and quality of service provision.

Since the new pathway has been introduced, we have seen significant improvements in several key metrics that measure quality of stroke services. Stroke patients right across Coventry and Warwickshire are now receiving high-quality care sooner than they were previously. This is an excellent example of how we’re delivering on our priorities to tackle health inequalities and improve access to health services.

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Using Proactive Care to support patients with long-term conditions

Multiple long-term conditions (MLTC) present a significant challenge to the NHS - with two-thirds of over 65s estimated to have MLTC by 2035. The Proactive Care approach is a model of community-based, multi-disciplinary working which aims to support older people to remain healthy, independent, and at home for longer.

Through a series of workshops, healthcare professionals are coming together to share the learning of current Proactive Care practices from Primary Care Networks (PCNs) and partners.

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Managing deterioration in Care Homes

Care home residents frequently find themselves in hospital because of health issues that could have been avoided with timely recognition of deterioration and an appropriate community-based response. 

The West Midlands Academic Health Science Network (WMAHSN) launched the Managing Deterioration Safety Improvement Programme in early 2022-23 and the Coventry and Warwickshire Deteriorating Residents project group delivered a multi-faceted project to support this through staff education and care home uptake of deterioration tools.

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