What we do..
The north of Buckinghamshire is a rural area with a higher than average number of socially isolated elderly people. This Service visits patients registered within the North Buckinghamshire Primary Care Network and aims to help them remain independent in their own homes for as long as possible. This could be achieved by helping them highlight the areas of their life they would like to improve and then signposting them to appropriate resources. Examples might relate to their personal care, nutrition, mobility, financial situation, managing a medical condition, improving their safety or reducing their feelings of social isolation.
From the outset, the aim of the service has been to work with older and vulnerable patients before they hit a crisis. The team receives referrals from GPs, members of the primary care team or patients’ families and patients themselves. The team also work proactively to find individuals who might benefit from the service, who suffer from a chronic condition and haven’t been seen in the surgery for over two years. Once identified, a member of the team member would then make contact and arrange an appointment. During the home visit, a full assessment will be completed and recommendations made on services which could help the circumstances, including referral to statutory and voluntary agencies as required.
In addition to the home visits, a 'Volunteer Coordinator' manages a group of over 30 highly-motivated and trained volunteers who give up their time to telephone clients for a regular social chat.
The Patient Support Team works as part of the North Buckinghamshire Primary Care Network alongside physiotherapists and occupational therapists, mental health workers, district nurses and adult social care. Having the ability to meet regularly, share patient records and cross-refer puts the patient at the heart of what they do.
During 2018, the Patient Support Service carried out 190 episodes of care in just 4 months. Anecdotal evidence from GPs suggests that the service reduces the need for home visits and helps prevent unnecessary deterioration in a patient’s health and well-being.
How we make a difference..
"A widower who was suffering from depression and low self-esteem due to their social isolation. The Patient Support Worker suggested that they could consider a voluntary role and, with their consent, contacted a National Trust property to arrange a trial period. This proved successful and they now feel a valued member of society – and have made new friends in the process."
"An elderly person confessed to the Patient Support Worker that they were struggling to manage their medication because they could not read or write. By sharing this information, the GP and the pharmacist could now ensure that all instructions are given verbally. Not only has this made the patient more confident it can also reduce the risk of hospital admissions."
"A patient, who was profoundly deaf, then lost much of their eyesight. The patient support worker found charitable funding to purchase a mobile device with a speech-to-text function so they could more easily communicate with family, friends and GP. This 'transformed' their life"
From the beginning
Originally we were formed as the 'Over 75 Team' but with changes in referrals and closer working with other professionals, as part of a wider Integrated Team, we are now known as the 'Patient Support Service' and better describes our role and Service to you.
Where we are now
We currently have a team of 'Patient Support Workers' and one will be allocated to visit you in your own home to assess your needs. We also have access to a team of trained and vetted 'Patient Support Volunteers' and other external voluntary or charitable based organisations via our 'Volunteers Coordinator' to deliver additional Services.