The Ageing Well Service is a local NHS service, operating on behalf of and as an extension of the usual registered GP practice, who remain responsible for certain elements of patient care. Our service was established (and has been evidenced) to improve access to timely, high quality and holistic (person-centred) care for both care home and house bound patients, as well as improving continuity of care through provision of dedicated care home clinicians.
Our Ageing Well programme aims to:
- Promote a multidisciplinary team approach where professionals from the NHS and social care work with their communities in an integrated way to provide tailored support that helps people live well and independently at home for longer
- Ensure that the care and support people receive is based on their wishes, preferences, and aspirations, particularly towards the end of their lives
- Offer more support for people who look after family members, partners or friends because of their illness, frailty, or disability
- Develop more rapid community response teams, to support older people with health issues before they need hospital treatment and help those leaving hospital to return and recover at home
- Offer more NHS support in care homes including making sure there are strong links between care homes, local general practices and community services.
We provide regular clinical care to people who live in care homes across Chesterfield & Dronfield. Our Multi-Disciplinary Team includes highly qualified Community GP’s, Advanced Practitioners, Paramedics and Care co-ordinators for assessments of patients that require this. In addition to this the Ageing Well team visit the home if a patient should become acutely unwell.
We will ensure that a person’s clinical care and treatment is based on their own wishes, preferences and aspirations, through advanced care planning. This involves our clinicians’ creating conversations with their families or legally appointed advocates.
The specific aim of our approach is to provide continuity of care for residents with access to multi-disciplinary input when required.
If a patient requires onward referrals to other services, our team will co-ordinate this through collaborative approach.
Ageing Well is part of the Derbyshire Team Up Initiative which is creating one team across health and social care who see all the people in a neighbourhood who are currently unable to leave home without support.
Team Up is not a new or ‘add on’ service – it is a teaming up of existing services and the creation of additional capacity – with general practice, community care, mental health care, adult social care and the voluntary and community sector all working together and with their local communities.
There are four components of this urgent community response service. These are:
- Home visiting services – whereby people are being visited at home by a range of different health and care professionals – overseen by the primary care networks
- Rapid response nursing and therapy services – provided by Derbyshire Community Health Services
- Adult social care rapid response services – provided by local authorities and increasingly being integrated with NHS services
- Falls prevention and falls recovery services – which are being expanded across the city and county under Team Up.
The Ageing Well team can directly link patients into any of the services above seamlessly without delay or impact on the patient.
There are a range of bereavement services that can offer help and support through this difficult time, please download this Bereavement Leaflet for service information.
Where the Ageing Well / Home Visiting Service Service is available
This map shows the area that the Ageing Well Team covers for the care homes and home visiting across our PCN. If you need this information in a different format, please contact the PCN.
