This is a multi-professional cross sector collaboration including health, social, community, 3rd sector and supporting staff in Coatbridge, North Lanarkshire that has worked tirelessly immediately prior to and since the Covid 19 pandemic.
They have enthusiastically developed a preventative approach for community dwelling older adults at high risk of deterioration across 3 General Practices (population approximately 16000). This has been done despite the work being paused at the start of the pandemic with an understandable focus largely on emergency work.
The team includes community staff from rehabilitation, nursing, health visitor, mental health, care at home teams, Equals Advocacy (3rd sector advocacy organisation), frailty specialists (secondary care), information technology, pharmacy, primary care senior decision makers and Public Health Scotland and they have embraced this new way of working without any additional resource.
Other stakeholder involvement has included community dietetics and Scottish Ambulance Service.
Coatbridge has significant urban deprivation and North Lanarkshire Health and Social Care Partnership (HSCP) has the lowest number of GPs per head of population of any HSCP in Scotland. Despite these challenges both locally and as a result of the pandemic they have, (in less than 2 years) developed tested and are starting to spread this intervention to neighbouring localities. In particular, throughout this Equals Advocacy and primary care have worked seamlessly together despite no previous relationship/ track record of collaboration.
There has been significant reduction in anticholinergic burden risk, falls risk and overall reduction in pill burden in those who received MDT intervention. There was a saving of over £100 per patient per year from medicines optimisation and deprescribing. Further data is being collated analysing impact of MDT intervention on patients quality of life, hospital admissions and prescribing costs.
