Durham County Council and County Durham and Darlington NHS Foundation Trust

Supporting care home residents to stay in the community

Context

NHSX is providing national support across the seven NHS regions. The aim is to help localities expand existing projects that support patients, using devices or apps to help monitor their long-term conditions, or Covid-19 symptoms, at home. This project, supporting care home residents to stay in the community, is similar to others supported by NHSX.

County Durham has 96 older people care homes. Leaders of the local health system wanted to try to reduce the number of avoidable admissions to hospital from residents in those homes. Care home staff wanted quicker, more effective ways to refer their residents to community health services.

Approach

County Durham and Darlington NHS Foundation Trust (CDDFT) worked with partner company Health Call Solutions, Durham Dales Health Federation (a GP federation) and care home staff to develop a working prototype called Health Call Digital Care Home. It shares health information about residents and allows staff to access advice about the people they are caring for.

A four-month pilot in one care home allowed CDDFT and Durham County Council to refine their operational approach to supporting care homes, developing the digital system further.

After rolling out the solution, both the council and CDDFT continued to engage with care homes to identify further improvements – in particular, around individual cases where admissions were made.

Success

The solution now provides three functions. First, referral to community services, including immediate clinical advice for care staff. Second, a way to integrate key clinical observations into the health records of care home residents. Third, a monitoring function where deteriorations in vital observations lead to proactive support to care home staff from health professionals.

The solution is used by 97% of the older people care homes in the area, and the council estimates that before the COVID-19 pandemic, two hospital admissions were being avoided per month, per care home. Care staff are also more satisfied because they no longer have to wait on the phone to make a referral. The council and CDDFT are planning to roll out to other types of care homes by March 2021 and have expanded the service into extra care.

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