Newcastle CCG has published an informative guide, (click here), for any CCG or local service provider wishing to establish an Enhanced  Health in Care Home (EHCH) service  to ensure that every patient, no matter where they reside, has the best possible care.   The EHCH service model relies upon consistency, co-ordination and a multidisciplinary (MDT) approach with rapid access to specialist advice when necessary.  The service has geriatric assessment at its centre with shared care plans, access to specialist community services, and an integrated proactive case management approach to effectively manage the many complex needs of the patient.

The model relies on the following processes being in place:

  • Comprehensive Geriatric Assessment (CGA) and individual care planning to be integrated into every Primary Care IT system and shared with providers e.g. ambulance services.
  • Residents, families and carers actively involved in the planning process
  • A linked GP practice for every care home to provide maximum cover
  • Each GP practice has a named GP(s) to facilitate case management
  • A designated Older Persons Specialist Nurse aligned to care homes and, working with named GP(s)
  • Weekly care home ward rounds to identify individuals needing proactive care planning or reactive care (stabilising).
  • An MDT approach to care delivery with rapid access to specialists via a weekly virtual ward
  • Recognise and address learning gaps for all staff involved in MDT meeting through care-based discussions

How does the model work?

There are two main components of this model:  Care Home Ward Rounds and the Virtual Ward.

Care Home Ward Rounds

The purpose of the ward round is to co-ordinate clinical activities to enable the provision of timely, quality care for patients and their families – shifting the balance of care from reactive to proactive.  The ward round provides an opportunity for:

  • A combined review of a patient’s health by a GP, specialist nurse and a senior member of care home staff
  • Comprehensive geriatric assessment and the development of individualised care plans with the involvement of the patient, family and care home staff
  • Effective communication, information sharing (including care plans), and shared learning
  • Identifying residents requiring proactive care to remain healthy
  • Providing responsive care in a timely way
  • A whole system approach to care delivery

This is achieved by ensuring the following resources are in place:

  • Investment to allow participating practices to undertake weekly ward rounds in each home (time required for a ward round will vary according to the number of patients, their needs and the professional skills required)
  • Laptops to access to primary care records
  • Lead GPs and nurse specialists working with care home staff to prepare and schedule patients requiring review
  • MDT agreement for post ward round actions including access to specialist advice in the virtual ward
  • Nurse specialists and care home staff preparing patients and families in advance, when appropriate, to facilitate shared decision making
  • Involvement of other professionals as appropriate e.g. advocacy workers

The positive outcomes of the EHCH model are many but include; engaged, informed and involved patients and families, opportunities for cross organisational working and learning amongst health and social care professionals, and a reduction in hospital admissions.

Virtual Ward MDTs

The virtual ward maximises the numbers of patients able to benefit from the specialist input necessary to allow them to continue to either live independently in their own home or to stay healthy within the care home setting.  It is suggested that a virtual ward core team comprises; an Older People Specialist Nurse, Community Geriatrician, Old Age Psychiatrist, GP, and some Admin support, with the possible addition of therapists, social worker, pharmacist and dietician.  Learning from Newcastle suggests that the greatest value is gained from including the pharmacist in the Care Ward Round rather than the virtual ward, whilst Social Worker input is most valuable when undertaking a virtual ward assessment of patients living in their own homes.

The virtual ward process is as follows:

  • The team meet once a week in a centrally based care home.
  • Prior to the meeting the nurse specialists, and their partner care home link GPs, identify suitable patients
  • Relevant patient information is gathered prior to the meeting to inform decision making.
  • Intervention from Geriatrician, Old Age Psychiatrists on medicine changes, home visits, joint working etc.


The Newcastle EHCH model has achieved the following outcomes; A reduction in hospital admissions, outpatient appointments and A&E attendances and a reduction in GP visits and prescribing.  A future benefit is that as more and more care plans are put in place, patients will be able to record their preferred place of care and death.

To read the report in full please click here.