The Govan SHIP is developing a new model of care in General Practice which has been live since 1st April 2015.
Summary of project
At its heart is integrated working, principally between general practice and social work. But it is integrated care in the widest sense involving joint working with hospitals, the 3rd sector, voluntary agencies and other community based agencies as well.
The key aims of the project are best illustrated by the four sub groups which were created at the start of the project. These groups are; vulnerable children & families, frail & elderly, unscheduled care (in general practice, out of hours and accident & emergency) and information. The information group was set up to ensure we collect all relevant data in order that we can properly evaluate the project. Academic support is provided by Glasgow University to ensure rigorous evaluation.
The project covers the patients registered with the four practices in Govan Health Centre. These are Deep End practices meaning that they serve patients living within some of the most deprived post codes in Scotland.
What do we have? There are two attached Social Workers, one for adults and 1 for children and families. There are two salaried GPs shared between the practices to allow the experienced principals to be released and dedicate time to those requiring more input as part of the project. There is also dedicated project management and administrative support.
Underpinning the project are monthly multi disciplinary team meetings for each practice. Cases are identified in advance by any of the team members. These are then discussed at the team meetings and shared management plans are arrived at.
One of the principal aims is the sharing of information between all relevant agencies. One example of this is the ability to share GP information from the practice information system along with social workers having a laptop with them to share relevant information from their system, CareFirst, all on a live basis. This greatly enhances the ability to devise appropriate anticipatory care plans for patients of all ages in all settings.
Even though the project has only been live since 1st April, 359 cases have been identified and discussed at the multi disciplinary teams across the four practices.
Multidisciplinary Teams (MDTs) and Stats
This story involves a 3 year old child with known learning difficulties, who was on the Child Protection Register, initially over concerns with the child’s father who was a known offender. Appropriate steps were taken to prevent him obtaining access. It became clear after input from both the Health Visitor and Social Worker that there were issues around emotional and physical neglect involving the child’s mother. Significant support was provided to the child’s mother but, despite this, the issues surrounding neglect were not addressed. The child’s mother accused both her Social Work and Health Visitor of lying about the concerns that were being raised and also attempted to suggest that she had indeed addressed concerns around the child’s physical wellbeing, particularly in relation to diet. A multi-professional case conference was called.
As a result of the Govan SHIP Project, a GP from the practice was able to attend this case conference along with health visiting and social work colleagues and others. As a result, it was confirmed that the child was noted to have an iron deficiency anaemia which was secondary to deficiencies in nutritional intake with all other medical causes having been excluded. Health Visitor and Social Work colleagues were able to confirm the significant hygiene concerns raised with the housing environment and, equally, a failure to address the lack of emotional nurturing being given to the child. The child’s mother continued to accuse all professionals of falsifying their evidence and did not display any willingness to take responsibility for her actions.
Background reports on other family members revealed no suitable alternatives for providing care and, as a result, a recommendation was made to place the child in foster care.
Elderly, Terminally Ill
This story concerns an 80 year old female with terminal lung cancer who lived with a family member who has significant and ongoing addiction issues. The patient retained capacity and her wish was to remain and to die at home which posed significant challenges for all staff involved in this person’s care including GPs, district nurses, social workers, Cordia (home care service) and the dietician.
Including this patient in the Govan Project meant that the GP was able to attend a case conference and relay medical information and concern. This significantly changed the outcome. Prior to this, the patient’s son, who was her carer, had refused a key pad entry system in to the house, a smoke alarm system, and regularly refused access to Cordia staff. The door entry system was regularly not working and not accessible by this frail woman. The son was regularly out of the house meaning that, on many occasions, essential health care staff could not get access.
The GP’s involvement contributed to an improved outcome. A door entry system, accessible by the patient, and a key safe system were fitted. Prescribed medication would be placed in a locked box, which was only accessible by Cordia staff. It was agreed that if Cordia staff could not gain access to the patient’s house they would notify social work. The patient was therefore safely managed at home. Without this, it is likely that they would have required a prolonged hospital admission or a care home bed and this was unnecessarily avoided.
This story concerns a 22 year old with known personality disorder and anxiety illness. In seven years, this person had presented to Accident & Emergency 590 times. Multiple agencies were involved in their care, including psychiatry, general practice, emergency care, third sector support agencies and a prison liaison officer.
By including them in the Govan SHIP Project, the GP had time to attend regular Care Programme Approach (CPA) meetings. These were also attended by psychiatry, a prison officer, social work, Accident & Emergency and GP out of hours colleagues. A plan for a regular prolonged, 30 minute, appointment with the GP was instigated with weekly follow up by community psychiatric nursing and a clear plan for out of hours was written and documented.
Regular GP attendance commenced in January 2015 and continues to date as part of the project. There had been 30 presentations at A&E between November 2014 and January 2015. There have been only 6 presentations between May 2015 and July 2015. Prolonged weekly appointments with the GP and attendance at the CPA multi-agencies meetings would not be possible without the Govan Project.
This story involves an 88 year old patient who is housebound and lives with her son as her carer. She was seen at home with her son present. She was noted to have significant mobility issues due to osteoarthritis and was becoming unsafe in the bathroom.
The visit included a detailed examination. This demonstrated a previously undiagnosed bradycardia, i.e. a slow heart rate, which was causing dizziness and poor balance with a high risk of falls. The visit resulted in an alteration of this patient’s medication thus correcting the bradycardia and alleviating the dizziness. It also precipitated a referral for occupational therapy to assess the suitability for grab rails in the house to improve safety and again reduce the risk of falls further.
This patient did not request a visit nor did her carer. She was identified as part of the Govan SHIP Project and offered a visit by a GP. She was identified as part of the work within the practice at reviewing all patients over the age of 85 years who have not had contact with a GP or health care professional within 12 months.
Neither the patient nor her carer wished to contact the GP as they did not feel her mobility problems and dizziness were worthy of noting to the doctor. Identifying this at a routine planned visit meant a significant improvement in her health by a fairly straight forward medication change.
This case involved a 49 year who has frequently attended at both primary and secondary care with mental health issues as well as a number of known organic problems.
She was attending the practice on at least a monthly basis requesting a total of 15 separate repeat prescription items. In addition, she was also attending at least 4 secondary care specialities, again on a regular basis. An extended 40 minute care plus planning consultation was undertaken with the patient and a joint management plan drawn up with patient agreement to rationalise her current complex management. This was instituted over the coming months with continuity of care and consistency of management applied and will be an ongoing process, in a graduated fashion, throughout the remainder of the year.
As a result of the agreed management plan with patient co-operation, the number of repeat medicines has been reduced from 15 to 8 to date with the patient herself reporting an improvement in their overall symptoms; in particular, they now report to feeling less sedated than previously.
In addition, the number of secondary care specialities attending has been reduced to a single speciality with an annual review appointment only.
Elderly, with Dementia
This story concerns a 66 year old with dementia whose social circumstances are extremely poor. Their carer is their daughter who has significant addiction issues. There were significant concerns for this person’s safety at home although they wished to remain there and had capacity to make this decision.
Enrolling this patient in the Govan SHIP project allowed a round-table discussion with multiple agencies. This included joint visiting with social work and addiction teams who were involved with the carer and also by psychiatry. GP attendance at multi-disciplinary meetings allowed for the sharing of additional information, which could then be passed on to the carer. This resulted in enhanced engagement with the carer, care staff and social work. A plan was set in place to allow Cordia (home care) to gain access for personal care and support and Key Housing (housing association) were able assist in improving the standard of cleanliness within the home.
Without involving this person in the project, the GP would not have been able to attend multi-disciplinary team meetings and communication between these multiple agencies would have been extremely difficult. The outcome would have been non-engagement with the carer and other agencies.