A healthcare programme in Kirklees has been recognised nationally for improving support for frail patients through a patient focused partnership.
The SPEN Primary Care Network (PCN) won the SystmOne GP Excellence Award. This award was decided amongst SystmOne users through a vote. Recognition was given after a presentation of its work with GPs, Patients, and service providers was shown.
This initiative was launched in response to the high number of frailty diagnoses across the PCN, with one in eight patients effected. The PCN has been working alongside patients, GP’s, and Service Providers to try and understand the factors which influence Patients health and wellbeing.
The network’s seven practices collaborated to create both a tailored patient list and establish a multidisciplinary team to review how they could improve care for those who would benefit from this approach.
Dr Danielle Nimmons, Academic GP at Liversedge Medical Centre, PCN Clinical Director and the lead clinician behind the project, said: “Each partner is an expert in their field, and it is empowering them to improve the lives of our patients.”
She added: “We’ve seen positive results within just six months, and we are looking to roll this out across all the PCNs in North Kirklees.”
The process found that both mental health and social care issues play important roles in improving patients’ quality of life. The found that other factors played a role, like GP-led support, rehabilitation, personalised plans, and medication reviews.
Danielle and her team would like to see their work spread across the country and network.
The presentation can be viewed on YouTube.
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