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Addressing vital conversations - care planning can be a topic that is often delayed or avoided entirely, however, best outcomes occur for everyone when the topic is addressed head on. Join us Thursday 14 Jan at 2pm to hear more from Willows Health, Leicestershire's leading provider of general medical services and a recognised innovator in improving health and care for their patients. Click below to "get your tickets".
At Willows Health, they have engaged in a large programme of proactive care planning for some of the older and most frail patients they look after. This developed after recognition that certain groups of patients, where their baseline in terms of comorbidities and frailty markers would predict a likely decline in their health in the fairly near future, did not have advanced care plans put in place. Willows believed for this group of patients a lack of a care plan possibly led to many adverse outcomes, but we also examined some of the common reasons from a clinician and administrative point of view why such care plans were not done or discussed in a more proactive manner.
This led Willows Health to take a population health approach to this cohort of frail older patients in order to improve patient outcomes and experience as well as improve end of life care for these individuals. The team consists of experienced general practitioners, the unique insight and overview of a consultant geriatrician working in our group, GP trainees and a number of administrative persons also. More recently this has been supplemented by the addition of a palliative care nurse in the team. By using validated tools, Willows have been better able to identify individuals who may benefit from advanced care planning and intervene in this regard at an earlier stage of their care. This proactive approach has been helped by delivering regular training sessions and feedback sessions to clinicians and students about doing this work and how to have a structured approach to it. Many of these aspects of the programme have been led by the experienced consultant geriatrician working in Willows Health, which has certainly provided general practitioners and trainees/students an absolutely invaluable resource in primary care to learn from and evolve their own practice.
The results of the work thus far have been encouraging from a patient, clinician and educational perspective. Early indications and evaluation suggests a correlation between the care planning programme and reduced hospital admissions in this group of patients as well as reduced length of hospital stay overall. There are also multiple examples of patients’ overall care being optimised, including a reduction in polypharmacy, as well as end of life care being arranged in a very compassionate, timely and effective manner. They have also established a direct relationship between the presence of an advanced care plan and achievement of preferred place of death. Due to the impact of this work directly benefitting patient care and outcomes as well as potentially ensuring better allocation of resources our efforts have been recognised locally by the clinical commissioning group (CCG) and further afield on a wider scale. The next steps of the process are engaging in high quality research about the overall potential impact of our work, from both a qualitative and quantitative perspective based on sets of well defined markers of good quality care. Willows are hugely excited by this opportunity to improve patient care and share learning for this very important cohort of patients that they look after on an everyday basis.
Join us Thursday 14 Jan at 2pm, click below to register.
Willows Health is the largest primary care organisation in Leicestershire serving over 44,000 patients over 9 sites. We are committed to finding real-world evidence-based solutions to improve the lives of the patients everywhere We believe in using innovative models of care to provide the very highest quality of care to our patients.
Through close collaboration with the National Institute of Health Research (NIHR), Demontfort University, and the University of Leicester, we have one of the strongest research footprints in the East Midlands.
Our own in-house academy provides world-class undergraduate medical education to the clinicians of tomorrow whilst our postgraduate faculty works with Health Education East Midlands to deliver the highest quality of training for tomorrow's healthcare leaders.
We closely collaborate and partner with ACHE (Academy of Community Health Experts) to deliver specialist care in dermatology, ENT, ophthalmic, urological, and orthopedic surgery. This provides access to high-quality specialist care closer to home.
We aspire to become one of the premier primary care providers in the world.
Dr Vinay Gupta, Director; Willows Health
Vinay is a Director of Willows Health overseeing the operational & clinical staffing strategy, finances, and engagement in research opportunities related to the care of older people. He also looks after the residents of the local mental health rehabilitation unit and the delivery of Willows Health urgent care services.
Vinay has coordinated and implemented the delivery of personalised care planning for some of the frailest patients of Willows Health, the outcomes of which have been recognised both locally and on a wider scale. His role within the Digital Health Unit at De Montfort University complements this nicely as they push forward towards remote technology in the appropriate setting to improve the overall care of service provision.
Vinay is a keen teacher and one of the founders of the Willows Academy, which provides high quality undergraduate and postgraduate educational experience and promotes excellence in teaching within the primary care setting, strengthening his links with Leicester Medical School where he taught an undergraduate course and was an examiner.
Dr Richard Wong, Consultant Geriatrician Willows Health, University Hospitals of Leicester NHS Trust.
Richard is the Clinical Director of Older People’s Health for the organisation and oversees the care and service provision for these patients. Within Willows Health he has thus far overseen and guided the proactive care planning programme delivered by the group and provides invaluable expertise in terms of ensuring this is completed to a high standard. He has also engaged very closely with the care homes that the group looks after, both in terms of carer education and delivery of the recent National Care Home DES that has been rolled out. His leadership of a multidisciplinary team to achieve this has certainly shown beneficial outcomes and in this regard he works closely within the Primary Care research unit Willows Health has recently formed with DeMontfort University.
In addition to looking at the role that digital technology can be used to improve patient outcomes, the vision is to engage in high quality research about our work in order to share best practice and facilitate the improvement of patient care across the board.
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