Community Response Team – Safecare Network

The Safecare Network has established a care partnership with local acute hospitals Northern Lincolnshire and Goole NHS Foundation Trust (NLAG) and Humber and North Yorkshire Integrated Care Board (ICB). The Community Response Team provides a proactive service within the community. It helps all the Care homes within the NL area to support their resident’s needs including end of Life care patients’ medication advice etc. CRT team help and supports the EMAS team, and local podiatry team.

This was noted and evidenced from our data capture exercise that this clearly reduces hospital admission.

This is a 7 day, 8am to 8pm GP role located at Global House, Scunthorpe. The GP will advise and support community health and social care teams including SPA, EMAS ambulance crews, local GPs and the Unscheduled Care Team.

The role does not involve visiting patients or seeing them for face-to-face appointments. Consultations and advice will be provided via telephone or virtual routes.

This function may include:

Respond to urgent/crisis health needs for patients who are transferring onto the Virtual Ward (as per their discharge plan)
Provide support to the management of medical issues for anyone moving into the step up/down beds via the daily care home round (i.e. as above)
Undertaking an “intermediary” role with the patient’s registered GP when patients have complex MDT arrangements post discharge back to Primary Care
Taking the clinical lead for the MDT discussion for patients who, on discharge from the hospital, are returning to an unchanged situation. This means there is a reasonable possibility that readmission will occur unless action is taken. The MDT will be responsible for enacting the plan once agreed. This may include, for example, a referral to the SAFE service.

CRT GP Senior Decision Maker

The CRT GP will be the senior decision maker, looking after the management of acute medical needs and other needs which may lead to reduced re-admissions, keeping patients’ preferences in mind.

The CRTGP will be actively engaged in the MDT work to support the Discharge 2 Assess team which enables patients to be discharged from SGH in a rapid timescale.

The CRT GP will be “on duty” at Global House to receive requests for medical advice and intervention from every team working in Global House and remotely from the East Network Community Teams. This advice will be given face to face to clinicians within Global House and remotely via telephone and video link (AccuRx) when out in the community.

The CRT GP should be proactive and welcoming of work. If you have free time then you should ask SPA if you can be of any assistance.

The work of the CRT GP will vary each day and according to whether GP practices are open.

The CRT GP will assist SPA by focussing on the secondary triaging and management of:

UCT visit requests in order to reduce the number of avoidable visits. This will at times include assessing patients by telephone or video and prescribing appropriately.
The CRT GP will particularly advise and support decision making relating to hospital admissions and advanced care planning and will provide advice to the SPA team before ambulances are dispatched.
If a patient has been triaged by the CRT GP and is assigned a UCT visit the CRT GP should whenever possible hand over the patient verbally to the UCT member who will do the visit. In addition to this verbal handover the GP should follow the instructions for booking the visit on Systm1 that SPA will provide. If hospital avoidance though urgent care planning is desired the UCT member should be made aware of this and encouraged to contact the CRT GP during the visit to sort it.
If the CRT GP works regularly at a GP surgery they are encouraged to inform SPA as they may have knowledge of patients on the SPA call list that could be of benefit and they may wish to take over their management.
The CRT GP will liaise with the patient’s usual GP when necessary and appropriate. A post-event notice will automatically be sent to the patient’s practice to inform their GP of the encounter. Safecare Network Limited- Temporary Services for COVID-19.

The role of the Community Response Team

Reduce hospital admissions

Reduce avoidable and inappropriate hospital admissions. The CRT GP will advise and support clinical decision-making relating to alternatives to hospital admission.

Reduce readmission

Reduce readmission in patients discharged from secondary care.

Respond rapidly to requests

Increase visit capacity within the Unscheduled Care Team (UCT) and other community teams by responding rapidly to requests for GP advice.

Advanced care planning

Support more patients to die in their preferred location through rapid advanced care planning.

Faster access to palliative care

Support more patients being able to ‘die well’ due to faster access to palliative care medications and guidance. The GP will issue palliative care medication prescriptions and nursing drug cards where needed.

Increase GP capacity

Increase GP capacity within primary care by the above needs being directed away from practices. The CRTGP will be able to co-ordinate rapid responses in a very efficient way by having easy access to the range of services available to support patients at home. The CRTGP will liaise with the patient’s GP whenever this is appropriate.