About us
Guy’s and St Thomas’ (GSTT) has provided community services in the two London boroughs of Lambeth and Southwark since April 2011. Since then, in collaboration with local partners, we have made significant progress in developing new pathways and delivering local services that keep adults and older people well at home, avoid hospital admissions and ensure safe and swift transfer home.
In April 2019, the Trust decided to make integrated Care its second Strategic Business Unit (SBU). Our SBUs are groups of clinical directorates with common challenges or a shared strategic agenda, managed by a dedicated senior leadership team and led by a director. The Integrated Care SBU brought together 2,500 staff in our adult community, therapies and acute medicine services, plus specialist palliative care staff and the Trust’s discharge team. The key objective of Integrated Care is to develop internal and external relationships and partnerships, supporting collaboration to deliver improved and more joined-up services to our patients and local populations. The SBU’s extended leadership group includes a social work advisor who is currently the Deputy Director of Adult Social Care for Lambeth Local Authority, as well as a GP advisor from each borough.
Our pre-COVID work with Care Homes
Geriatrician support
We undertook a six month pilot of geriatrician liaison, providing four hours per week to care homes in Southwark from June to December 2016. This demonstrated the utility of the approach as illustrated in Figure 1.
Figure 1: Summary of findings from 2016 pilot of geriatrician liaison to care homes in Southwark
| · 27 visits with 149 patient reviews. An average of 24 patient reviews/month (range 16-26)
· 291 clinical interventions – many resulting in reduced need to attend Outpatient clinics (often reducing repeated need for clinics) · Likely admission avoidance cases where acute illness re-diverted to our @Home service · 109 changes to medication required: – 84 medications stopped/reduced during 38.3% of reviews – 25 medications started/increased during 17.4% (26/149) of reviews |
Following the 2016 pilot we provided geriatrician support to residential homes in North Southwark, extending this to nursing homes from 2018. This now totals 2PAs (8 hours per week). This includes supporting monthly MDT meetings, Comprehensive Geriatric Assessment (CGA) reviews, aiding with Advance Care Planning (ACP), secondary care linking and other problem-solving between multiple agencies. Following the introduction of monthly MDM meetings with a revised structure and documentation in nursing homes in October 2018, the percentage of residents dying in their care home rather than in hospital increased from 67.9% to 78.5%.
In collaboration with King’s College Hospital NHS Foundation Trust (KCH), geriatrician support was provided across the rest of the two boroughs as follows:
- South Southwark: 1PA (4 hours per week) flexible support provided by KCH
- North Lambeth and South West Lambeth: 0.25PA (1 hour per week) per home, flexible support provided by GSTT
- South East Lambeth: no funding but flexible support provided by KCH as able
The findings of the 2016 pilot also led to a review of GP cover to care homes. Since 2017-18 this was provided in Southwark by Quay Health Solutions (one of two GP federations in the borough). In Lambeth, provision was a mixture of individual practices managing one home and a couple of practices managing two+ homes, with routine GP care organised by individual practices and varied depending on resources and needs.
Extensivist pilot
In October 2018 a pilot commenced in Southwark with a Band 8a nurse in an extensivist role. This included supporting Comprehensive Geriatric Assessment (CGA) and Advance Care Planning (ACP) in care homes – a review of MDT meetings suggested that these were best completed face-to-face with the resident and their family separately from, but supported by, the MDT. There has also been success in embedding Coordinate my care (CMC) in homes when uptake was poor or where patients in care homes were on CMC, but the GP was unaware. Almost 100 CGA, ACP and CMC documents were completed within the first four months of the pilot. Other achievements of the extensivist pilot were developing relationships with care home staff, working alongside GPs, making contact with visiting health care professionals, managing acute episodes, falls assessments, rationalising outpatient appointments and medication in conjunction with pharmacists and making onward referrals where unmet needs were identified.
@home care home pathway
Care homes could also directly refer to GSTT’s @home service, which provides a range of services to support patients in their normal place of residence, preventing unnecessary admission to hospital or helping patients to return home sooner with extra support. However, there were difficulties with capacity and with the pathway.
COVID response
GSTT’s COVID-19 command and control structure included a Community command structure, the remit of which included the implementation of the Hospital Discharge Standards, published on 19 March 2020. A partnership response was considered crucial and the membership of the Community tactical group included both Lambeth and Southwark social care and CCG partners, as well as KCH, with the group linking into the Lambeth and Southwark multi partner response groups.
One of the workstream priorities identified was ‘Supporting our care homes in Lambeth and Southwark’. The activities and achievements of this workstream have included:
Clinical network development
A clinical network for Lambeth and Southwark was operationalised comprising representatives from care homes, GPs, secondary care professionals (palliative care, geriatricians, psychiatrists) and community professionals (e.g. pharmacists, and Clinical Nurse Specialists). WhatsApp was used, with a governance framework to keep within Information Governance guidance. This enabled a mutually productive professional relationship between multiple professionals across different organisations and a rapid sharing of new guidance and educational tools.
A wide range of problem-solving took place, e.g. sourcing PPE urgently for care homes, urgent medication access, finding a specialist to speak to immediately. The network was also used to advertise local and national webinars and community of practice meetings. A Google Drive of national guidelines/documents was created for easy access to relevant guidance.
Multi-organisational Community of practice Zoom meetings have also been trialled in Southwark to aid further discussions and joint problem-solving and planning by e.g. GPs, care homes, palliative care, geriatricians and psychiatry.
COVID tracking
A tracking system was developed to identify care homes with potential COVID outbreaks in order to co-ordinate/advocate additional clinical support. The system used a combination of the Local authority ADASS tracker, feedback from the care home network and a weekly review of admissions to KCH and GSTT. The tracking enabled us to adjust our clinical response to deliver added support where it was needed most.
GP provision
The workstream facilitated change in GP provision for acute response. In Southwark a 7 day care home specific GP on-call service 8am-6.30pm was commenced, with increased resource for greater virtual and visiting capacity. In Lambeth an escalation mechanism to the Clinical Cabinet was developed, so that individual practices could up-escalate need for greater input and access to GP resource, with a system to escalate to secondary care where geriatrician input could bridge clinical needs. In both boroughs, there has been an increased focus on reviewing advance care plans and discussing with families where needed.
Geriatrician provision
GSTT and KCH have worked together to cover care home needs, flexibly assisting virtual and face-to-face reviews, regardless of traditional boundaries of responsibilities. There has been much greater clinical input than previously in Lambeth, both virtually and face-to-face.
GP/geriatrician co-working
There has been much more flexible working, with less division of roles to deliver the clinical care required at the time, (e.g. if a GP was unable to go to a home at a specific time, a geriatrician may go. Where specific care homes have needed greater secondary care support, help has been put in place flexibly).
Flexible acute care
Where current community services were unable to aid an acute need, (e.g. short term subcutaneous fluids whilst the @Home team regained capacity), GPs flexed to delivering interventions temporarily in patients’ best interests.
Psychiatry support: Care Home Intervention Team
There has been increased flexibility to advise in challenging cases.
@Home service
An improved pathway for acutely unwell residents in care homes has been co-developed.
Access to palliative medication
The workstream advocated strongly for the provision of rapid access to medications in End of Life (EOL) patients in care homes, the need for which can be rapid in frail older people. An in-hours access pathway was put in place, with out of hours access planned to be signed off via a hospice/hospital EOL pre-pack system.
Carer mental health
There have been a number of psychologist initiatives locally for care workers and we have worked together to collate information on how these can be accessed.
COVID testing
The workstream enabled securing laboratory and CCG agreement in Southwark for testing symptomatic residents in care homes. At the time of writing a plan for Lambeth was being submitted for CCG sign off.
Conclusions and the future
The key to the success of this work has been the strong, mutually productive professional relationships developed across different organisations for the benefit of patients.
A key future initiative would be to scope and plan an education strategy together with care homes. This could include:
- Training for care workers: e.g. using RESTORE2 amongst other things and using coaching and other models rather than “training”.
- Undergraduate education – examining how to embed the training of undergraduate nursing and allied health professionals into care homes with appropriate mentorship.