Nene Valley Hodgson Medical Practice has a Personalised Care Team which involves Care Coordinators, Social Prescribers, Primary Care Matrons and a Pharmacy Team, with having additional clinical supervision. Our aim is to deliver a targeted service to patients who are frail, vulnerable and in need, to promote good health and prevent problems before they happen.
Care Co-ordinators
The top 1% of most frail and vulnerable patient cohort has been identified using coding on records. We carry out an assessment either over the phone, at the patient’s home or at the surgery to create a Personalised Care and Support Plan to reveal what areas of a patient’s life are going well and where they might benefit for us to help promote their independence. This assessment highlights unmet needs. Patients are made aware that we are here if they need to discuss any non-medical concerns where we actively listen to find the root cause of the problem.
We have also identified patients 75 years+ who have not been in contact with the surgery and have not had any medication prescribed. We are signposting to appropriate services while helping navigate through health care.
We are notified of discharge letters when a patient over 75 comes out of hospital where non-medical input is required so that we can make contact to ensure they are supported.
We ensure patients with learning disabilities come in for their learning disability annual health-check. This brings physical and mental issues to the surgery’s attention. We take into consideration barriers and put in reasonable adjustments where we can.
A representative from Aspire comes into the surgery to provide alternative ways to manage chronic pain and support patients to reduce their reliance on medication. We ensure patients on these specific medications are monitored and booked in to the appointments available.
Patients who have heart failure and diabetes are often significantly frail and at risk of health problems. We have a Doctor with a specialist interest who works with these patients. We ensure that these patients are identified and booked in for their review.
We accept referrals from Doctors, Nurses and the reception team who believe they think the patient is in need of our support.
Amy – Care Co-ordinator
Amara – Care Co-Ordinator
Social Prescribers
Social prescribers who work in the GP surgery are experts in doing an assessment of what care and support some of our patients need. They help people to connect with community groups for practical and emotional support. They are able to provide help to patients for things such as physical activities, learning new skills, making new friends or finding employment, signposting to outside services.
For further information, please visit the following website: NHS England » Social prescribing
Wendy – Social Prescriber
Kiralee – Social Prescriber
Saida – Social Prescriber