Older people with social care needs and multiple long-term conditions

Establishing the role

A wide range of local stakeholders, including care home representatives, were involved in a Vanguard workshop to look at developing a new model of enhanced health in care homes. As part of this they outlined what a care coordinator role would involve. Care coordinator roles already existed in both residential and nursing homes, with both healthcare assistants and registered nurses taking on this role. Some of their job descriptions were used as templates to build on and a final draft was then reviewed by the Vanguard's work stream group for final approval.

Roles and responsibilities

The care coordinator role is carried out by senior registered nurses based in the nursing home. Their job is to provide leadership to improve the standards of care and quality of life for all residents. They are the key liaison point between primary care and the resident and their families, coordinating referrals to other services. The holistic health and social care needs of the resident are considered and a care plan is developed to meet the resident's needs. A key part of the job is to lead weekly health and wellbeing rounds carried out with the linked GP for the home.

Requirements of the role

Care coordinators need to have an interest in maximising the health, wellbeing and independence of residents and the ability to advocate effectively. They also need enhanced care skills relevant to the type of home, for example end of life care, dementia care and so on. As part of the pilot, care coordinators have received training from Sutton Care Home Vanguard to increase their clinical and leadership skills on topics such as care planning, safeguarding and team working.

Allocating a care coordinator

The care coordinator role is always carried out by a senior nurse, and each home only has 1 or 2 senior nurses so the choice of care coordinator is limited by this.

Care network

Care coordinators work closely with a wide range of health and social care professionals and organisations, for example GPs, care home pharmacists, continuing healthcare team, chiropody, dentistry, physiotherapists, challenging behaviour team, befriending services from Age UK, ambulance services and community providers (such as speech and language therapists, dietician, end of life care nurses, tissue viability and occasionally other specialist nurses).

Health and social care context

The care coordinator is a permanent member of staff at the care home. The additional support and funding for the role has come from being part of the Vanguard programme.

Making a difference

Early findings from the pilot suggest that GPs and nurses have more structured time available to discuss care needs with residents and their families. This helps with decision making and involving the resident in discussions on their needs, both now and in the future. Care coordinators are saying that they have greater confidence in their communication and leadership skills, are more assertive, and have more knowledge now of the support available. GPs report a more professional relationship with the care coordinator, resulting in better person-centred care and a more collaborative approach to decision making.

Overall, the Vanguard programme has seen a reduction in non-elective hospital admissions and ambulance conveyances across all their nursing, residential, learning disability and mental health homes. However, these outcomes cannot be attributed to the care coordinator role alone – the Vanguard programme has many other initiatives to support good practice in care homes.

Financial benefits

It is anticipated that the impact of the care coordinator role will be reduced unnecessary hospital admissions, reduced ambulance conveyances and reduced spending on medications through comprehensive medication reviews carried out by the community pharmacist working alongside the GPs and care coordinators.

Learning points

An interim evaluation of the pilot is underway. A number of learning points have come to light already: