Elderly man smiling

Working with a PCN to develop a Community of Care

By working collaboratively and harnessing the skills and assets within the community, we delivered new models of care focusing on the needs of a population - joining up a true care community and coming together to improve the health and wellbeing of a local population.

The challenge

Mosaic Healthcare PCN wanted to identify and deliver new models of care focusing on the needs of their population and how these needs could be met by working collaboratively and harnessing the skills and assets within the community. 

We were commissioned to work with them to: 

  • understand the care needs of the population through population health analysis
  • develop an understanding of the non-clinical needs of people attending primary care services
  • identify providers of care in the geography – health, care and voluntary or charitable sector
  • develop new models of care including social prescribing, signposting, care navigation and multi-disciplinary-team approaches built around the needs of the population

What we delivered 

  1. We facilitated the development of care segmentation models to identify the needs of the population, using both primary care and secondary care data, and mapping it to illustrate geographically where those of greatest need reside.
  2. We undertook community-based mapping through both desktop research and on-the-ground interviews to identify providers of care and additional community resources (assets) in the geography. 
  3. We arranged and facilitated stakeholder workshops with the public, patient participation groups and clinicians, to develop a shared vision for the population and explore opportunities to work differently to meet their needs.
  4. We developed impact measures across health and care using evidence-based reviews on the potential impact to support the development of a robust case for change and business plans.

In investigating the health needs of the population, the team identified that many of the non-clinical issues patients brought to the surgeries were of a technical nature such as housing and benefits, and therefore beyond the experience of the medical teams. They then sought support from other services to provide non-medical support in these areas to deliver solutions that resulted in:

  • Employment of a Social Prescriber supported by an administrator to link patients in primary care with sources of support within the community. This provides GPs with a non-medical referral option that can operate alongside existing treatments to improve health and wellbeing.
  • Establishment of a weekly patient review with Social Services on-site - attended by the practices Community Matron, Paramedic and Social Prescriber.
  • Appointed Citizens Advice to deliver daily clinics to support patients with concerns relating to issues such as housing and benefits. 
  • Introduced MSK, Counselling, Podiatry and Diet clinics. All are fully booked and have enabled patients to access services up to 10 weeks earlier.

The outcome

Stakeholders worked closely together to deliver key benefits for patients including the introduction of Improved Access, with both surgeries offering appointments to all patients within the PCN footprint each evening and on Saturdays. Using community-based assets to support those people who present with no clinical issues or issues that arise from non-clinical matters appropriately outside of General Practice, enabling clinicians to spend more time with those with more complex care needs.

At the highest level: 

  • I've seen and discharged 16 patients
  • I am actively working with 29 patients
  • I have three new patients booked in
  • I have six referrals awaiting an appointment

 I have developed social prescriptions which included prescribing all sorts of things - meals/food, exercise, counselling, social activities, transport, befriending, voluntary work (for the patient), bereavement services, coffee mornings/lunches, religious services, referral to occupational health, meditation, Citizen's Advice, elderly care charity signposting, child care/holiday activities, take a break for carers, shop mobility, personal alarm systems, cleaners and domestic help, singing, care home visits, Al-Anon (relatives of alcoholics, etc).

We have received some wonderful feedback. Two ladies discharged yesterday who feel their lives are back on track and are both getting out socialising again and making friends, a blind lady who is so much happier and says I've transformed her life, a gentleman today who cares for his wife with dementia that can see a way forward and things they can do to make life easier. 

All in all huge job satisfaction for me and truly made an impact on our patients! - Sarah Smith, Social Prescriber, Mosaic Healthcare 

The Board of Mosaic used the success of this joint working as the catalyst to review where joint working would further enable the surgeries to offer people access to other services, without the sole route of access required through a GP. The outcome of the review was a clear focus on social prescribing, closer relationships with social services and voluntary organisations, and supporting the frail population.

Dr Sam Hullah, Mosaic Healthcare’s Clinical Director, commented that both surgeries have noticed the immediate positive impact social prescribing has had for approaching 50 patients in just a matter of a few weeks. Many of these patients have had 2 or 3 contacts with Sarah, and as a result have not been seen by a GP, freeing up valuable time for us whilst giving the patients prompt access to the services they need.

For more information This email address is being protected from spambots. You need JavaScript enabled to view it., Director of Primary Care


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