Enhanced Health in Care Homes (Including Learning Disability Homes)

People living in care homes should expect the same level of support as if they were living in their own home, but this can only be achieved through collaborative working between health, social care, voluntary, community, and social enterprise (VCSE) sector and care home partners. 

Enhanced Health in Care Homes (EHCH) moves away from traditional reactive models of care delivery towards proactive care that is centred on the needs of individual residents, their families and care home staff.  Care providers work in partnership with local GPs, PCNs, community healthcare providers, hospitals, social care, individuals, and their families. 

The EHCH framework is designed to ensure that care and support is coordinated and consistent, that any interventions are offered as early as possible to meet the individual’s needs, to improve outcomes and promote independence for people living in care homes. 

The EHCH Framework is structured around seven care elements:

1. Enhanced primary and community care support
2. MDT support including coordinated health and social care
3. Falls prevention, reablement and rehabilitation including strength and balance
4. High quality palliative and end-of-life, mental health, and dementia care
5. Joined-up commissioning and collaboration between health and social care
6. Workforce development
7. Data, IT and technology

Personalised are and support are at the heart of the EHCH model with three principal aims:

1. to deliver high quality personalised care within care homes
2. to provide the right care and the right health services (temporary or permanent) for care home residents in a place of their choice
3. to enable effective use of resources, reducing unnecessary conveyances to hospital/hospital admissions, whilst ensuring the best care

Every care home:

• is aligned to a primary care network (PCN)
• has a named clinical lead (who is responsible for overseeing implementation of the framework)
• has a weekly ‘home round’ supported by the care home multidisciplinary team (MDT)
• has established protocols between the PCN, care home and system partners for information sharing, shared care planning, use of shared care records and clear clinical governance.

Every person living in a care home, within 7 working days of admission or re-admission:

• has participated in a comprehensive personalised assessment of need undertaken by the MDT
• has participated in the development of their personalised care and support plan (PCSP) with a member of the MDT
• care home residents should be identified and prioritised by their PCN as people who would benefit from a structured medication review (SMR)

Leaning Disability Team:

We are a part of the Enhanced Health in Care Homes team, working closely with Care Homes/Supported Living Homes, GP surgeries and the Community Learning Disability Team based in Hartley Hospital. Our main goal is to reduce the risk of admission to hospital through proactive care. Our care coordinator conducts weekly care home rounds with staff, discussing residents who may need support. We can then liaise with clinical professionals and send referrals on resident’s behalf, taking pressure off staff and GP’s.

Our Nurse Associates conduct Learning Disability Annual Health Assessments for practices who have signed over responsibility. We offer every Learning Disability patient a review every year, where we can discuss their overall health, take observations, and talk with the patient and their families about problems or concerns they need support with. Referrals are made on behalf of the patient, including to Social Prescribers, the Community Dental Team, Occupational Therapy and Community Learning Disability Team.

The EHCH Team

John Chatham –   Clinical Lead

Jayne Williams – Senior Care Coordinator

Andrea Kearley – Care Coordinator (Bootle)

Rosie Kelly – Care Coordinator (Crosby)

Kath McElroy – Care Coordinator (Seaforth & Litherland)

Abi Carter – Care Coordinator (Maghull)

Sarah Parr – Trainee Nurse Associate (LD Homes)

Sarah Campbell – Nurse Associate (LD Homes)

Callum McCavish – Care Coordinator (LD Homes)