The new approach focuses on supporting patients with more than one long-term condition and frailty from becoming reliant on emergency care. Developed with health and care partners across Kingston and Richmond, health, voluntary and social care organisations work together to provide patients with the individual care and support they need.
Working across two PCNs in Kingston and Richmond, the PAC pilot launched in May 2021, with GPs and other professionals referring suitable patients. As a result, people have told us they feel more confident to manage their own care and that they have confidence that the team works with them, their family members and/or carers to support them with the development of a personalised care plan. Results for the pilot also show a significant reduction in unplanned care attendances after patients have been involved in the project for more than four months.
We are gifted the time we need to really get to the bottom of what’s going on, for patients, their carers, and families. I am such an advocate of PAC, I can see we are taking the pressure off and strengthening the system.”Karina Wills, Care Coordinator
As part of the roll out, several more Care Coordinators have been recruited. This role is crucial to the project and is the direct link between patients, their families, and the multidisciplinary team.
Shaheena Khan, Care Coordinator
Shaheena has been with the PAC project shortly after it began as a pilot over two years ago. She joined the team with a background as a Social Prescriber which has helped with her role as a Care Co-ordinator. She explained: “PAC has always been an exciting project to be involved with and the results speak for themselves, and that is just with one PCN. Expanding across the borough and beyond will be fantastic for local people. My colleagues and I see it day to day as we work with the patients referred to us. People get so much comfort from being under our care and having that support. Often, they are older and frail and can really struggle with understanding referral pathways and what support is available to them in their local area. Often, they are unable to use the internet, but we can help them navigate all of that. It is incredibly rewarding when we step people down from the project, knowing we have been on the journey with them and that our intervention has made a difference, and given them the tools to help them move forwards with their lives.”
Karina Wills, Care Coordinator
Karina joined the PAC project over two years ago after spending time working in local GP surgeries. She said of her role: “Having worked with GPs for a long time I can really see the benefits of this project as vulnerable patients come straight to us without needing to see a GP if there isn’t an immediate clinical need. We are also able to help those that have become disengaged from local care and act as the patient’s voice when they need us to. A lot of patients have become a bit lost in the online world and although social prescribing is amazing, they aren’t able to spend as much time as we can assessing whether someone’s circumstances are putting them at risk of intervention. We are gifted the time we need to really get to the bottom of what’s going on, for patients, their carers, and families. I am such an advocate of PAC, I can see we are taking the pressure off and strengthening the system.”