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GPs introduce care plans to reduce hospital stays for at risk patients

25th November 2014 | By Liz Mattock | Posted in

More than 16,000 patients at high risk of being admitted to hospital are set to benefit from a new type of individual care plan designed to keep them healthy and at home.

The introduction of the plan, developed by local GPs as part of the Leicester Better Care Fund (BCF), is for patients who have been identified as being at very high risk of being admitted to hospital as a result of chronic long term conditions such as heart disease, diabetes and lung conditions.

Under the initiative those identified as being at very high risk of being taken to hospital will have in place personalised care plans and receive frequent routine assessments to monitor their condition more closely. This means any deterioration in their health can be picked up sooner, helping to avoid a spell in hospital.

The personalised plan acts as a complete guide for everyone involved in the patient’s care. Previously, without the plan in place, a patient would most likely have gone straight into hospital for treatment and may have experienced re-admissions as a result of not having the support they needed in their own community.

So far 3707 patients have benefited from having a plan in place since the introduction of the scheme in August. It is estimated that around 16,000 will be completed over the next two years.

Dr Nitin Joshi, one of four project leads on the BCF programme, speaking on behalf of Leicester City Clinical Commissioning Group and Leicester City Council, said: “Previously we were unable to bring together a patient’s medical, social and psychological care needs under one plan, but thanks to the commitment from partners under the Better Care Fund, we are able to work much closer and more efficiently to deliver a better package of care.”

The care plan contains information about the patient’s condition and individual care needs to manage the condition safely and well, outside of a hospital setting. It holds information such as medication, when they will need a health review, a history of their appointments and details about their general health and wellbeing.

Housebound patients will be cared for at home, eliminating unnecessary journeys to hospital. Patients over the age of 75 will be assigned a care navigator to support their social care needs, allowing them to live independently for longer, in their own homes.

The Leicester City Better Care Fund (BCF) is a joint fund between Leicester City Clinical Commissioning Group (CCG) and Leicester City Council, supported by local health and social care partners, and provides a new integrated health and social care service.

The BCF will apply across the UK from April 2015. However, the combined efforts of the local health and social care partners means that Leicester people are already benefitting from a more positive experience and a better quality of care.

For more information speak to your GP or log on to our website http://www.leicestercityccg.nhs.uk/find-a-service/our-services/better-care-fund/ to read about our plans under Better Care Fund.

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