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Affinity Care, a Bradford-based GP partnership, has created a home visits team helping to keep vulnerable people living in Wyke, Thornton, Queensbury and Denholme healthy at home and out of hospital.

Rather than GPs conducting home visits to these patients in a short window of time between clinics, Affinity Care created the new full-time service where different members of a multi-disciplinary team visit patients at home.

Known as the Complex and Housebound Care Team (CHCT), the team is made up of a GP, advanced nurse practitioners and senior healthcare assistants who all go out to visit patients in their homes. The team helps people in care homes, those with learning disabilities, people receiving end-of-life care, and the elderly. By conducting home visits this allows them to offer continuity of care and allocate more time and resources to reduce hospital admissions.

Louise Clarke, GP and Programme Director Healthy Communities at Bradford District and Craven Health and Care Partnership, said: “This is a great initiative. A huge number of hospital admissions are avoidable with the right care in place. Care in the community often results in better outcomes than those treated in hospital; people get better rest without the sounds of a busy ward and loud machinery, there is a reduced risk of infection, and people are surrounded by loved ones in a familiar environment. By expanding the care provided in the community, our most vulnerable, frail and elderly patients can be better supported to continue living independently.”

The team works with community healthcare professionals, including district nurses, community matrons, and nursing home staff. There is also full-time dedicated telephone access for patient queries, advice and support from allied healthcare professionals (AHPs). Working collaboratively reduces duplication and makes the best use of collective resources.

Rob Daw, partner at Affinity Care, said: “Healthcare assistants carry with them a TytoCare device, which enables them to link remotely with a GP or advanced nurse practitioner to undertake a full assessment of a patient including respiratory, cardiac and ear, nose and throat examinations. Ours was the first team in Yorkshire and The Humber to implement and use this technology successfully.

“Our team regularly receives feedback from patients and our community colleagues about their positive experiences with the new collaborative and dedicated way of working. We have built good working relationships with our community colleagues, with better patient care and a culture of open discussion and learning.”

A local campaign, ‘It’s a GP Practice Thing’, aims to increase public awareness of how GP practices are working, including community-based, non-medical support services which are available to help meet people’s needs.