This case study has been provided by Liz McCourt, Project Manager on behalf of Seisdon PBC, South Staffordshire PCT.

This ongoing project involves all Gravel Hill Surgery and Dale Medical patients aged 65 and over. The Unique Care office is based at the Dale Medical Practice.

The first step was to distribute questionnaires to all patients aged 65 and over. The results were analysed and used to determine risk and the responses entered in to the Emergency Admission Risk Likelihood Index computer software to calculate risk of hospital admission.

Nearly 2,600 questionnaires were sent out and there was an 89% return rate. Following this, 68 high and 51 very high risk patients were identified. Non responders will be followed up.

The team started their work by assessing the highest scoring patients and identifying any who needed to be seen as a priority.

They asked the practice GPs to carry out medication reviews and a home visit summary to inform the assessment process.

Care plans were then developed for each patient.

Beyond the initial questionnaire, a number of protocols were formalised for continued identification of potential risk, and management of patients.

Referral: The initial identification of patients using EARLI. This only determines the initial risk category prior referral to the Unique Care team.

Dependency stratification: This is a tool used to evaluate ongoing patient dependency. Its function is to rate the risk of hospital admission, identify risk of disease, structure the patient's priority with the caseload and suggest care strategies.

Patient prioritisation: The team assesses need from the risk assessments, health care professionals and GPs.

Patient pathway: Initial contact, assessment of needs, care planning and communications.

A copy of each patient's individual care plan and Single Assessment Process paperwork is placed in the front of the Social Services' yellow folder that is kept in the patient's home. A more detailed Unique Care folder is also kept in the patient's home.

The out of hours care is provided by the intermediate care team, evening district nurses and Wolverhampton Doctors on Call.

A key component of the project is to establish hospital in-reach. Both Dudley and Wolverhampton hospitals have been informed of the project and are supplying information on a daily basis on patients admitted via emergency. This enables the Unique Care team to cross-check against their register, so that their discharge can be managed at the earliest opportunity. This also enables a review of the patient's needs and whether their care plans need to be amended.

A major factor in the project has been the identification of staffing requirements. The two posts that have a critical bearing are the community matron and the social worker, who are both in post.

To be successful the project has to be linked together with other services. Age Concern, community mental health teams and the dementia care support worker have been included to help needs identification and the promotion of the service.

Initial contact has been made with the out of hours provider and a further meeting is scheduled with them and also the ambulance trust to raise awareness of the project.

The lead time for the project took longer than anticipated due to the complexities of working across health and social care services and a desire to ensure this is a truly integrated service.

There is real commitment from Social Services who have released a social worker who is dedicated to this project and are exploring potential roll-out to other practices.