Case study:

22 December 2008

Care-Plus Project in Tower Hamlets PCT and London Borough of Tower Hamlets

Key points

Tower Hamlets PCT and London Borough of Tower Hamlets have set up a ground-breaking project to support carers of patients with end stage heart failure through a co-ordinator who acts as a primary link and single point of contact for medical and social care services.

Care-Plus identifies what support carers require – whether that is of a health, social, emotional or financial nature – and then arranges for that support to be provided as quickly as possible.

The result is that carers feel well-informed and supported and this in turn makes it easier for patients to choose where they wish to die.

Care-Plus seeks to reduce carers’ social isolation and furnish them with the information they need to support the patient with confidence.They should also be better prepared to resume their life once the patient dies.

At the same time it increases patients’ choice and control and reassures them that the carer is being looked after as well.

The project has involved extensive coordination between all the statutory and voluntary sectors in the borough both to identify those in need of support and to ensure services are available when they are needed.

It is hoped that the project, which began in October 2006, will cut the number of emergency admissions and bed days in acute care as well as GP home visits and hospital outpatient visits. It should also reduce patient and carer stress and improve communication between professionals and the patient and their carer.

Setting up the service in the first place required a huge amount of groundwork.Publicity material was distributed to health and social care providers, general practices, social work teams and to all patients and carers. In addition a large number of information-giving events took place across the borough.

The team, which consists of a Project Co-ordinator backed up by a multidisciplinary steering group, has also produced a carers information pack and a DVD on heart failure for all carers and patients.

The resulting service acts as a single point of contact for the carer. It also provides an enhanced advocacy service and undertakes one-to-one case work with the carer. A case synopsis is written for each case and is regularly updated.

The three-year £150,000 project is funded by the King’s Fund with a one-off additional contribution of £15,000 towards evaluation costs from Tower Hamlets PCT and the London Borough of Tower Hamlets Adults Health and Wellbeing. It is hoped, however, that the service will eventually be mainstream funded by the PCT.