Sowe Valley Primary Care Network (PCN) in Coventry, wanted to build a resilient, anticipatory and targeted care model which focused on patients who were high intensity users of primary and secondary care services to reduce demand particularly during the winter period.
With support from Arden & GEM, the PCN has been able to clearly articulate its vision of empowered patients, confidently managing their conditions and translate this into a new Resilient Patient Pathway.
A successful funding bid has enabled Sowe Valley to begin implementing a 9-step plan for delivering the pathway through a year-round multidisciplinary team (MDT) providing preventative, personalised care which supports patients in managing their own conditions.
Sowe Valley PCN formed in 2019 when nine practices, with a combined patient population of around 80,000 came together in the east of the city of Coventry. The practices are geographically spread over areas of affluence and deprivation, with a number of pressing and varied priorities, including poor health among BAME and transient populations, and people with long-term conditions and disabilities.
The PCN had successfully bid for winter pressure funds in 2021/22 to enable the creation of an MDT care coordination hub, focused on providing anticipatory care in the community to the top 250 high intensity users of primary and secondary care.
Sowe Valley wanted to build on this approach by expanding the scope of the team and increasing the cohort of patients seen, moving the concept on from anticipatory care to a resilient primary care team able to reduce demand by targeting interventions early, making it easier to absorb additional demand in the winter.
Arden & GEM’s Health and Care Transformation team worked closely with the PCN’s leadership team to create a long term vision for this approach which was underpinned by the following principles:
- An MDT intervening quickly and early when a crisis or deterioration occurs
- Scheduled and structured patient follow up
- Patients empowered to manage their conditions.
Building a patient pathway
The CSU spent time listening to the PCN leadership team talk about their vision of happy, healthy patients who are supported to self-manage at home and whose contacts with primary care are multidisciplinary and focused on interventions that deliver the outcomes that matter to them. This vision was distilled and translated into a visual pathway.
The result was the Sowe Valley Resilient Patient Pathway, built around an MDT including social prescribers, a health and wellbeing coach with specific training in weight management and diabetes control, Community Psychiatric Nurse, GPs and care coordinators.
The role of social prescribers
Social prescribers are key to the resilient patient approach, encouraging patients to play an active role in self-management of their conditions and to access help and support within their own communities, for example, to combat loneliness and increase activity levels. Social prescribers also manage relationships with local initiatives able to support with signposting.
Funding the 9-step plan
With an agreed model and pathway in place, the PCN now needed funding to make this vision a reality. The CSU team put together a bid for funding from the Coventry and Warwickshire ICB Population Health, Inequalities and Prevention Board.
The successful bid won £41k for the PCN and was based on a 9-step plan, developed by Arden & GEM, which included:
- Four Action Learning Sets to develop further existing topic guides (clinical guidelines) targeted at the high intensity patient cohort
- Accredited staff training in areas such as diabetes care
- Engaging with local community groups to enhance or develop resources for self-management and self-help
- Pharmacist-led medication reviews for the entire patient cohort
- An evaluation of the project’s impact including changes in demand for GP appointments and unplanned hospital admissions.
As part of the bid development process, Arden & GEM conducted a review of the strategy landscape so that the funding proposal was aligned with and linked to system priorities and established approaches to population health management.
With support from Arden & GEM’s Health and Care Transformation team, Sowe Valley PCN now has a clearly articulated and funded model for anticipatory and targeted care.
This is captured in the Resilient Patient Pathway which delivers a year-round MDT approach to working with patients who are high intensity users of primary and secondary care, helping to avoid crises and hospital admissions.
"Arden & GEM helped us to coherently explain our vision of empowered patients confidently managing their condition with lifestyle changes, with MDT support, as part of the Health Creation approach, we have fostered over the past few years.
Thanks to the CSU’s input our bid for funding was successful and we have already run the PCN's first specialist training session on diabetes for our social prescribing and health and wellbeing teams."
Tim Morris, Director at Sowe Valley PCN