Provision of Proactive Nursing Services for NHS Southampton City CCG

Background and Context to Services People do not suddenly become frail, it happens over a number of years.

Previously our Long Term Conditions strategies focussed on single conditions, with professionals working in silo pathways of care and responding to crisis situations.

It is well known that the reduced need for long-term care can be achieved by proactively identifying those at risk earlier to ensure the correct support is in place in a timely way.

The Better Care Southampton Strategy has identified the need for more joined up services for patients.

Southampton City CCG (SCCCG) is working together with Southampton City Council and other voluntary organisations on a programme of change that aims to transform the way people in the city receive treatment and support for their health and social care needs.

The long term aim is to integrate all services that an individual might need by removing barriers and organisational boundaries.

During 2015-16, in response to the “Everyone Counts” initiative and part of the Better Care Southampton overarching strategy, SCCCG supported practices in transforming the care of patients aged 75 and older and reducing avoidable admissions by piloting the ‘Personalised Care for over 75 year olds’ service.

The pilot aimed to enhance the role of community nursing teams to proactively support the 2% of patients identified through agreed criteria, which includes the Avoiding Unplanned Admissions DES, Risk stratification and GP knowledge.

This service was provided by nurses and healthcare assistants who undertook proactive screening, assessment, signposting and navigation for patients who are deemed to be at risk but not in receipt of core community service provision.

The pilot was outcome focussed and driven by individual needs identified by the GP.

Care is personalised to promote control, self-management and independence at home.

Interventions take a holistic approach to address an individual’s specific need.

In response to the lessons learnt in the evaluation of early work and the population profile within the city, the age range for the pilot has been expanded in advance of the Procurement to include the adult population.

Southampton has 86,000 people living with a long term condition with over half having multiple conditions.

In the city this situation is not confined to the elderly, indeed in a recent analysis of people who experienced more than 3 admissions to hospital in the last year, 64% were found to be in the age band of 19 – 64.

The model for Procurement will include all those aged 18+ registered in Southampton City who have a specified need for proactive care, where this is not already provided by other core and specialist community services.

Budget/ Financial information £1,000,000 - £1,200,000 per annum The contract length will be 3 years from the 1st April 2017 with 1 x extension option of 24 months