Working collaboratively
SWGP worked collaboratively with Age UK Warwickshire and 31 GP practices – initially on a one-year pilot project – to establish a proactive approach whereby patient’s needs, whether clinical or social are identified earlier, increasing quality of life and reducing risk of hospitalisation.
Depression and social isolation affect one in seven people over the age of 65 (Graves et al 2006). This project allowed this to be identified earlier and subsequent care to be put in place.
The integration of Age UK GP Navigators within the GP practices extended the practice reach into the social and emotional aspects of prevention as well as helping to identify earlier diagnoses of dementia and atrial fibrillation.
Outcomes in year one
- Reversed the upward trend of non-elective admissions for over 75s: 2.6% reduction in year-on-year non-elective admissions, compared to a rise of 5.3% in the previous year.
- Halted the upward trend of A&E attendances for over 75s: 0.2% increase compared to a rise of 8.6% in the previous year.
- Earlier diagnosis of dementia, atrial fibrillation and depression in the elderly, with at least 95 new diagnoses of dementia and 85 new cases of atrial fibrillation attributed to the project.
- 98% (2198/2244) of patients agreed that the enhanced clinical reviews have ‘been beneficial to their health’.
- Better integration of services to provide more joined up care for the elderly
Due to the success of the initial pilot, SWGP was commissioned to continue the project for two more years, incorporating learning from year one.