Enhanced Health in Care Home service

The Directed Enhanced Service (DES) set out guidelines for Enhanced Health in Care Homes to strengthen care and support for people living and working in care homes. The collaborative approach centres on the needs of the individual residents, their families and care home staff. This is achieved by a multi-disciplinary team of health, social care, voluntary, community, and social enterprise (VCSE) sector and care home partners work together.

Residents receive more co-ordinated and proactive care, delivered where they live. This supports:

  • better outcomes for residents through better management of their long-term conditions
  • a reduction in unplanned hospital admissions
  • a reduction in hospital as the place of death

Residents have access to enhanced primary care and to specialist services and maintain their independence as far as possible by reducing, delaying or preventing the need for additional health and social care services.

Individual personal care plans are created with residents so that they are involved in their health care choices. 

If a resident has limited capability to understand the health care choices, these choices are created with the support of their care home, family, friends or advocate putting the resident's best interests first.

Multi-disciplinary team meetings

The Bridgwater Bay PCN includes 9 GP practices based in the centre or outskirts of Bridgwater. Each GP practice is aligned to one of our 10 older people care homes based in and around Bridgwater.

Following the DES specifications, our Care Coordinators provide a weekly multi-disciplinary team (MDT) meeting which includes the community nursing team, occupational health team, older persons mental health team, pharmacist, clinical team leader and various other teams.

Meetings are usually held over an computer conversation, where someone from each of the MDTs joins the call as well as a representative from the care home. 

The needs of the resident are discussed and the MDT endeavours to reach a decision during the meeting that meets and supports the individual needs of the resident. Residents are usually chosen by the care home if they have noticed a particular change or decline in a resident's health, or they feel that the resident could benefit from extra support. It’s a way of having the discussion with all the relevant teams before a referral to the appropriate service is made.

Team members can also arrange a visit to review a resident on the call saving the GP and care home time. This often helps the resident get the help they need faster by missing out the weeks of waiting for appointments. This works particularly well for those residents with complex care needs, palliative care needs, dementia care, mental health, end of life comfort and those residents with high risk of falls. Members of the MDT can also request care homes bring certain residents to the MDT meetings so they can review them without visiting the care home.

MDT meetings are not for urgent or chronic on-the-day help, these requests must go through to the relevant GP or emergency service.

What care home staff say about MDTs

“The multi-disciplinary team meetings are the best thing to be implemented. The PCN Care Coordinators make sure the right people are on the call to help deal with residents’ complex healthcare issues. For example, one of our residents started to decline rapidly after recovering from Covid. Their overall health deteriorated with weight loss, repeated urine infections, and reduced mental wellbeing. During the MDT meeting, a plan was put in place to address the health concerns and a referral was made to the Parkinson’s Team. The resident is now off their medication, receiving the right treatment and their health is improving”.

“The multi-disciplinary meetings are well organised and planned. Time is given to each case to explore all healthcare and wellbeing avenues so that residents get the right treatment or referral to the right specialist team. The PCN Care Coordinators keep the care home informed of progress and we can pass that news on to reassure residents’ families”.

Team meeting

Staff training

The care coordinator service also supports care home staff by providing or signposting them to support and training. Our Listening and Responding to Care Home (LarCH) team are very good at providing education and support to care homes. Our care coordinators can arrange LarCH training to support residents health needs.

Structured Medication Reviews

Under the DES specifications, residents receive a yearly Structured Medication Review with our pharmacist. The pharmacist talks through the resident’s medications with them personally. This helps the resident to understand what medications they are taking and the long term risks that may be associated. Some medications may have an impact on the resident's long term health.

If the resident lacks the capability to understand the Structured Medication Review, this may be undertaken with the care home manager, family and friends.

Moving from hospital to care home

Our care coordinators support with the weekly discharges from hospitals and the new admissions to care homes. Residents moving from hospital to care home may need extra support as they settle in.

We also provide all care homes with an NHS.net email address to maintain resident confidentiality and safety.

Further information