Wakefield CCG’s new £6m hubs that are designed to connect health and social care to prevent avoidable hospital admissions have so far been successful, the commissioning group has claimed.
An important element of the Connecting Care Hubs is providing mobility equipment to would-be hospital patients immediately, which may prevent them needing to go into hospital.
The hubs have multiple agencies working together, all under one roof, to support patients with health and social care needs who could otherwise receive fragmented care, with multiple referrals and handovers.
This means that people only tell their story once, usually to their GP, who refers them into the hubs to receive joined up care and support.
Once referred and assessed, the person might be visited by a nurse, occupational therapist, physio, social care worker, voluntary worker, housing officer or mental health worker.
In six months the hubs have seen almost 2,000 people including 636 urgent referrals.
Jo Webster, WY&H CCG’s lead and chief officer at NHS Wakefield CCG, said: “People only want to tell their story once and then they want a solution.
“Many elderly people don’t have a single medical condition or social care problem, they need a package of help which meets their needs and what we’ve done in Wakefield and in other areas of WY&H is to provide that.
“If someone has fallen for example and might be living on their own and socially isolated, they can be referred into the hub for support with all of these factors, which may be impacting on their health and wellbeing.”
Between 2015 and 2035, the numbers of older people with four or more diseases will double and a third of these will have mental-ill health.
One in three people admitted to hospital as an emergency has five or more health conditions, up from one in ten in 2006/7.
Dr Phil Earnshaw, local GP and chair at the NHS Wakefield CCG, said: “This has been fantastic for primary care because it saves so much resource. We have more time to use our clinical expertise because there is a wider team supporting us.
“All we need to do when we have a patient who is appropriate for the service is refer into the Hubs and we know their needs are taken care of.
“The new electronic care record system we’ve introduced means we can all see the patient’s record and that all individuals involved in someone’s care know what’s happened to that person from the beginning to the end of their journey.”