Case Study – Everton Road

Social workers and matrons team up in Liverpool

The Everton Road joint health and social care team in Liverpool was set up two years ago in response to high emergency readmission rates at the city’s largest teaching hospital, the Royal.

The team, composed primarily of social workers and community matrons, is based at a health centre in Everton, one of the city’s most deprived neighbourhoods. Its brief is to avoid unnecessary hospital admissions, including emergency readmissions, and to reduce the length of in-patient stays. Admissions tend to come from the local area which has a white, working-class population, some of whom have drug and alcohol problems. Long-term conditions, such as chronic obstructive pulmonary disease are also a big issue among people from their mid-fifties.

Team manager Steve Walsh says the team aims to prepare people for their stay in hospital, improve the quality of their stay once they are there and better plan their discharge. “The thing that should make a difference is a model of pulling people out of hospital rather than a model of pushing them out,” he says.

The team is focusing on working with people admitted with long-term conditions, who tend to be older, rather than those admitted due to drug or alcohol problems. Walsh says the latter tend to lead chaotic lives and can be difficult to sort out. They represent the next step in the team’s work.

Community matrons, who are trained nurses, represent a key part of the team. They have diagnostic skills and a higher level of skills and knowledge than district nurses.

“The district nurses would have provided nursing care as directed by a GP who wouldn’t necessarily have been very hands on,” says Walsh.

Before the team’s creation, the high volume of cases meant social workers or health staff put in support to help someone get over a crisis and then withdrew until another crisis emerged.

Instead the team works with older people on a longer-term basis. This enables them to quickly establish people’s history when an incident occurs so they have a better idea of what a person was like before they went into hospital and what needs to be done to move them back into the community. “This background is important in terms of readmissions,” says Walsh. “If you don’t have the background and you have to go out and deal with a crisis you tend to make safety net decisions and the safest thing to do is to refer somebody to casualty. Locums do that.”

“Given that we know people when the crisis happens we are much more able to take a risk and provide support at home because of the knowledge we have of the patients and the family. We will take risks because we know people.”

While Walsh says it is difficult to show whether the team’s work is reducing hospital admissions due to the numbers of factors involved, he is confident it is leading to a cut in the number of emergency readmissions.



More from Community Care

Comments are closed.