Cooperation

The three PCTs covering Bristol and South Gloucestershire are working in a close partnership to adapt and implement the Evercare model. The size of this community means that different approaches can be trialled and the lessons learnt applied elsewhere. Most of the fourteen Advanced Primary Nurses (APNs) are working with patients living in their own homes, linked with their own GP practices. However we also have two nursing homes directly working with an APN. The demographic range and the size of the practices is a deliberate mix, and includes inner-city areas.

Social Services

An important practical link has been made with the local Social Services & Health departments. Advanced Primary Nurses are kept up to date about which of their patients are also receiving support from Social Services & Health teams. This is one step further towards the integrated services that both organisations are striving to achieve.

Hospital links

Excellent progress is being made with our local Acute Trusts concerning:

• process for notifying the Advanced Primary Nurse (APN) on the day following emergency admission of an 'Evercare' patient,
• The expectation that an APN will usually visit the patient in hospital, and always liase with the Discharge Team or Ward
• Developing working relationships between APNs and key Ward staff
• Professional development through linking each APN with a senior Clinician (e.g. SpR, Medical or Nursing Consultant)

Community involvement

We held our second stakeholders' event in August, attended by about 25 representatives of local organisations. It was recognised that there were three levels of engagement with the community of carers and support groups. Some issues needed to be widely communicated, others needed consultation and the third category was active involvement. The main messages from our local community were that we need to tap into the knowledge and networks already in place, and that any involvement must be genuine.

Education and professional development

Through collaboration with a local university, a work based learning module has been developed to complement the clinical training of the APNs. About to start this Autumn, it will be giving them the opportunity to study and gain credits at M level.

Martin Howard on behalf of the 3 PCTs

Evercare Project Facilitator

Bristol North PCT

Tel: 0117 9003414

Email: mailto:martin.howard@bristolnorth-pct.nhs.uk?subject=Evercare