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Deborah Graham, who is working with care homes in East Northants

Elderly patients are benefiting from a new pilot care home nurse scheme to help look after people living in residential and nursing care. The aim is to work with the care home supporting the management of their long term condition and reducing the need for hospital admission.

NHS Nene Clinical Commissioning Group (Nene CCG) has commissioned an advanced nurse practitioner to visit care homes in the East Northamptonshire locality and ensure the most vulnerable patients are getting the additional support they need.

Deborah Graham, an experienced nurse who has worked in the East Northamptonshire community for 12 years, was appointed to the new role in May 2012, and is employed by Northamptonshire Healthcare Foundation Trust, Nene CCG’s provider partner for the scheme.

Deborah is working with 22 care homes across East Northamptonshire, identifying residents who have increasing health needs. She is working with the individual, the care home, GP, social care and the patient’s family to develop a health care plan that aims to reduce the need for hospital admission.

Deborah said: "A big part of my role is to make sure we collaborate with everyone involved in the residents care to improve overall health and wellbeing. Not only does this help avoid hospital admissions, it also helps ensure the patient receives care in their preferred place.

"I have access to all the community nurses and other specialist teams so if I am not totally able to deal with a patient myself, I will know someone who can. In some cases we do still need to send patients to hospital, but where possible we are able to care for very poorly patients within their familiar surroundings."

On a typical day, Deborah will receive most of her calls in the morning, and these are triaged and other health care professionals are involved where necessary.

Deborah added: "The patients I see are those who are acutely unwell, are having problems with their long term condition or may be at end of life. Care home staff are expert in recognising when a patient needs a review. The common conditions I treat include urinary tract infections, chest infections, and underlying anaemia’s and even the common cold.

"I carry out a number of investigations and prescribe the treatment and advice they need. I plan and follow individual care plans, agreed with the patient, their family, care home and GP. I can also arrange training and support for the patient and their carers to help them manage their condition as well as possible including liaison with the community pharmacist around medication issues.

"As well as having access to community nurses and other specialists I can contact Community Psychiatric Nurses for those with mental health needs including dementia."

Another part of Deborah’s role is helping to ensure patients wishes are respected at the end of their life, including ensuring the patient remains in their preferred place of care during the last days of their life.

Dr Glyn Williams, GP Chair for East Northamptonshire Locality for Nene CCG, said: "We are delighted with the success of the care home nurse pilot in East Northamptonshire so far, and the improvements in the quality of care for some of our most vulnerable patients."

"Last year there were 531 hospital admissions from care homes in East Northamptonshire at a cost of £1.4m. Of these, 11% (61) were patients at the end of their life, transferred from the care home to hospital.

"National research shows that around 70% of patients would prefer to die at home but the reality is that 60% of patients are still dying in hospital. Since the role started in May, we have ensured that 13 patients at the end of their life were able to pass away in the comfort of familiar surroundings (the care home) and according to their wishes, rather than being transported to hospital."