The Care Home Support Team (CHST) is a new service that will be launched following from a successful pilot scheme that was mobilised in December 2017. We now have funding to establish a permanent service across the HHCP partnership which comprises of a multi-disciplinary team, operating between Monday - Friday 9am - 6pm, with coverage split North/South. The service will provide support to the residents of care homes for older people in Hillingdon and Extra Care Housing schemes for patients registered with a Hillingdon GP. Weekend cover will continue to be provided by The Confederation Weekend Visiting Service who provide acute visits to Care Homes.
The team will initially consist of GPs and Care Home Matrons with wider support from a Mental Health Nurse, Care Home Pharmacist, Care of the Elderly Consultant and from next April, Dietician, Speech and Language Therapist and Tissue Viability capacity. The multi-disciplinary service will work collaboratively to create anticipatory care planning and provide an acute visiting service to the care homes and extra care housing within the borough.
The benefits of an integrated care approach is that the CHST will be familiar with the patients and be able to case manage them accordingly. The Care Home GPs will create anticipatory care plans for all residents within 2 weeks of that resident being registered with a Hillingdon GP. They will also carry out acute visiting to residents that require medical assessment and/or intervention which will focus initially on homes with the highest level of LAS call outs and transfers. The Matrons will provide regular visits: residential homes and extra care housing fortnightly and nursing homes on a weekly basis. The CHST will also co-ordinate with existing community services such as the CCTs, Your Life Line 24/7 and Specialist Community Nursing in order to provide holistic and appropriate care.
Care plans will be created using CMC (Coordinate My Care) which is a dedicated NHS clinical service created to deliver integrated, coordinated and high quality care planning, built around each patient’s personal wishes. The care planning process will be created based on a meeting between the Care Home GP, the resident, care home staff and, if possible, a next of kin so that the care plan is created and understood, jointly. These care plans will be updated on a 6 monthly basis unless clinically appropriate to update sooner.