AN INNOVATIVE ‘joined-up’ approach to elderly health care has started in Hillingdon.

The Hillingdon Health Care Partnership brings hospital services, GPs and community care together in Care Connection Teams, designed to help prevent emergency admissions to hospital among older residents, many of whom have complex medical conditions.

It also prioritises the identification of older people who might be at risk of an emergency hospital admission, and makes treatment in their own home the norm.

After a home visit from a Guided Care Nurse, which includes a top-to-toe medical examination and review of the patient’s medication, a care plan is drawn up, in consultation with family and carers, and given to the patient with guidance on how to use it.

For example, it might include information about symptoms, so the patient can call the team for advice such as when to start medication if their situation has changed. This helps to take pressure off GPs, reassures the patient that support is always available and ­– because they are known to the team and their treatment is regularly discussed – stops them having to endlessly describe their varying medical problems.

The whole system is designed to head off an admission to hospital, through the use of early intervention. It will be implemented across the London Borough of Hillingdon in early 2017.

HHCP comprises The Hillingdon Hospitals NHS Foundation Trust; Central North West London NHS Foundation Trust (CNWL); H4All, a partnership of voluntary sector health care providers; and Hillingdon’s newly formed GP Federation, which brings together all of Hillingdon’s GPs.

To watch a short video about the work of the Hillingdon Care Connection Teams, please go to http://intranet/index.php/comms/news2/828-integrated-health-and-care-partners-film