Protecting older people and supporting them to live safely at home for longer are just two of the aims of an innovative health project in Gloucester city.

Staff at Aspen Medical Practice in Horton Road have ‘mapped’ their list of more than 31,000 patients and identified those who would benefit from a specialist approach to their care. This included people living with dementia, as well as those who are housebound or have high levels of frailty.

The team works with these patients and their carers to prepare personalised care plans, covering everything from managing medicines to providing information about support groups that might be helpful. Patients are asked to think about ‘what matters to me’ before working together to achieve those goals.

This approach to care and support has helped the surgery to reduce the number of patients having unplanned hospital admissions as well as the number of requests for urgent appointments, whilst also improving the health and wellbeing of older people registered at Aspen Medical Practice.

The team received a commendation for their work at the NHS England South West Integrated Personalised Care Awards.

Dr Bob Hodges, GP partner and joint lead for Frailty at Aspen Medical Practice, said:

“We provide more than 250,000 appointments every year at Aspen. We know we look after a large population of older people, so want to help them and their carers to anticipate some of the health issues they might experience and tackle them before they happen.

“This helps our patients and their families. We know older people can often have complex needs and it is our job to help support them to live independently and healthily.

“We are real believers in integrated care so by joining up services as much as possible, we have a policy where any door is the right door and that is how we like to work.”

Rachel Bucknell is the Frailty Matron at Aspen; she heads up the practice’s Frailty Team which has two GPs, two matrons and two social prescribers all working together to help support patients who may be at risk of frailty.

Rachel explained that her team works with community services and voluntary groups to help support patients with their needs, this includes patients who are at home as well as those who may have been admitted to hospital.

She said:

“We monitor our patients as required, taking a personalised approach. We can use Sunrise EPR to check to see if they have been admitted to hospital or discharged home. If their needs are complex, we will liaise with whichever ward they are based on and offer to come to see the patient. Sometimes we will be invited to multi-disciplinary team meetings or discussions about the patient returning home.

“We will also keep an eye out for patients we haven’t previously seen when they are leaving hospital to ensure they get the care they need when they leave hospital.”

Rachel said:

“By having these conversations earlier we can help ensure a patient’s wishes are carried out, should they need to go into hospital. It is about treating each patient as an individual; no two people will need the same care plan or have the same identical needs.”