Pioneering health and social care Community Hub expanded to deliver wraparound care for frail patients in East Elmbridge

Pioneering health and social care Community Hub expanded to deliver wraparound care for frail patients in East Elmbridge

Pioneering health and social care Community Hub expanded to deliver wraparound care for frail patients in East Elmbridge

Frail patients in East Elmbridge are now benefitting from a more joined up service after the local Community Hub service expanded to include social care and reablement support. Following its success, further investment by NHS Surrey Downs Clinical Commissioning Group has meant that staff from Surrey County Council, together with colleagues from Surrey Medical Network and CSH Surrey, have been able to provide additional, personalised care to local older residents at home or in the community wherever possible. They can also help them relearn the skills required to keep them safe and independent at home following an illness or injury.

For the past 18 months a multi-disciplinary team of GPs, nurses and support staff, including social care, have been working together in East Elmbridge to provide healthcare that focuses on frail people with long term conditions ranging from dementia to chest infections and heart failure, who are at high risk of hospital admission due to an exacerbation of their condition, or a crisis. These patients usually have acute, complex health and social care needs and although not sick enough to be in hospital, require intensive support for a short period of time.

By bringing healthcare professionals together, the East Elmbridge Community Hub has found a new, more seamless way of working, which not only avoids unnecessary admissions but works with the patient on more preventative care, with an individual point of contact for each patient. Of 199 service users polled in a Community Hub survey, 97% said they would recommend the service.

Since the Hub’s services were commissioned in December 2015, the team have provided support to around 450 patients, and during this time we have seen a 4% reduction in emergency hospital admissions in this area for people over the age of 75 years.  This achievement is made more significant by being 9% less than other areas with similar populations, who have seen a 5% increase in emergency admissions.

Surrey Downs CCG believes that further investment in this service will ensure that patients receive higher levels of wraparound care and support within their own homes, to enable them to move out of crisis and avoid ill health. The recent addition of social care and reablement services within the Hub has meant patients have even more support in the community and can receive tailored care that meets their health, social and personal needs.

Dr Jill Evans, Local GP and Clinical Lead for the East Elmbridge Community Hub, said: “The hard work of the hub team and staff based at Molesey Hospital is evidenced through the direct impact that we are making to patient lives. We know that the data so far shows a significant reduction in acute hospital admissions, but what is really critical to us is the feedback that we have been getting from individual patients and their families. By providing support at a time of crisis we are ensuring that these people can be involved in making decisions about their care, and receive it in the most appropriate setting. With the inclusion of social care and reablement support, we can help those patients that do require treatment at Molesey Hospital to return home sooner, with on-going help in place.

“I’m extremely proud of the work that the East Elmbridge Community Hub has achieved, and excited that the CCG will be providing more investment to further enhance these services in the coming years.”

Mel Few, Cabinet Member for Adult Social Care at Surrey County Council, said: “This will ensure that the most vulnerable residents in Surrey get the care and support they need and much more quickly.

“We’ve worked very closely with CCGs in other parts of the county and those partnerships have proved similarly successful so we are delighted that we can now work together with Surrey Downs CCG as we try and help more people from having to be re-admitted to hospital through our reablement programme.”


For more information please contact the Surrey Downs CCG Press Office on 01372 201500.