Skip to main content

Enhanced Health in Care Homes (EHCH) e-Portal


what we do

EHCH Team - What We Do

The EHCH team delivers care to permanent residents in CQC-registered homes across Southport and Formby. The team delivers:

  • A comprehensive, holistic assessment - reviewed annually
  • Learning disability annual reviews and health action planning/reviews
    -to individuals identified as living with a learning disability.
  • Implementation and annual review of personalised care and support plans
  • Anticipatory/advanced planning,including:
    -treatment escalation planning (TEP)
    -ceilings of treatment (CoT) 
    -decisions about cardiopulmonary resuscitation
  • Structured medication reviews
  • Identification of patients who require addition to a GP's 'Gold Standards Framework' - a system for highlighting those who may, at some stage, require additional support. Such patients are reviewed at the monthly in-practice multi-disciplinary Gold Standards Framework (GSF) meetings. 
  • Education for homes
  • Referral to other services (i.e.: falls prevention teams)
  • Home ward round
  • Multi-disciplinary team input
  • Review +/- reassessment after patients have had a hospital admission
  • Review and assessments for any residents home staff may be concerned about

Digital Team

Our Digital Team offers support to the Primary Care Network and GP surgeries to:

  • Find those in need of support or treatment.
  • Find better ways to source and use data.
  • Help GP surgeries with any digital needs.
  • Improve access.
  • Test new software or technology.

The team work on lots of projects. This make a difference without being visible to patients

Enhanced Health in Care Homes

Our Enhanced Health in Care Homes (EHCH) team works with care home residents, their families and care home staff to:

· Offer personalised care

· Improve outcomes

· Promote independence for people living in care homes.

We offer assessments and personalised plans for care home residents. The aim is:

· To keep residents healthy

· Make sure health choices are respected

· Plan for future care

Our team delivers the National Framework for Enhanced Health in Care Homes. For further details see our EHCH E-Portal.

Early Cancer Detection

We work with GP practices to improve the rates of early cancer diagnosis. We do this by working together to look at data, processes and best practice guidance. The aim is to give the best care to all patients.

We also fund a team of Cancer Link Workers though Southport Macmillan Cancer Centre. They offer support to patients with a new cancer diagnosis and those living with cancer.  

The Cancer Link Workers meet with and listen to patients or their carer. They tell them about and refer to national support services that can help.

Your GP practice can refer you to the team. You can contact the centre on 01704 533024.

 

Health and Wellbeing Coach

Health and Wellbeing Coaches support people to take steps to improve their health.

They help people raise their knowledge, skills and confidence in managing their health. This can help:

· Stop illness

· Prevent existing conditions from getting worse

· Improve health and wellbeing outcomes

They can help by:

• providing coaching support to help you manage your health problem

• working with you to find out your health and wellbeing goals

• signposting you to helpful resources and support

Mental Health Practitioners

The service is hosted by Mersey Care. They have a team of mental health specialists offering non-urgent mental health assessments. This can be either in person or online.

The first appointment can be up to one hour long. They will ask you questions about your health and create a care plan. Follow up appointments are normally 30 minutes long. They may give advice or tell you about local services for support.

Your GP practice can refer you to this service.

Team of Clinical Pharmacists and Pharmacy Technicians

Our team of Clinical Pharmacists work across the area to support GP practices with appropriate prescribing of medications. Pharmacists have specialist expertise in the use of medicines, helping patients with their health. Pharmacists can also help people to:

· Get the best from medications

· Manage long-term conditions

· Complete medication reviews Pharmacy technicians play an important role, working with Clinical Pharmacists and other members of the team. Pharmacy technicians can:

· Conduct simple medication reviews

· Screen patients for onward referral

· Carry out medicine’s optimisation tasks

· Medicines reconciliation

EHCH Team - What We Do

The EHCH team delivers care to permanent residents in CQC-registered homes across Southport and Formby. The team delivers:

  • A comprehensive, holistic assessment - reviewed annually
  • Learning disability annual reviews and health action planning/reviews
    -to individuals identified as living with a learning disability.
  • Implementation and annual review of personalised care and support plans
  • Anticipatory/advanced planning,including:
    -treatment escalation planning (TEP)
    -ceilings of treatment (CoT) 
    -decisions about cardiopulmonary resuscitation
  • Structured medication reviews
  • Identification of patients who require addition to a GP's 'Gold Standards Framework' - a system for highlighting those who may, at some stage, require additional support. Such patients are reviewed at the monthly in-practice multi-disciplinary Gold Standards Framework (GSF) meetings. 
  • Education for homes
  • Referral to other services (i.e.: falls prevention teams)
  • Home ward round
  • Multi-disciplinary team input
  • Review +/- reassessment after patients have had a hospital admission
  • Review and assessments for any residents home staff may be concerned about

Important: The EHCH Team Does Not Deliver

An emergency response to acutely unwell or deteriorating end-of-life (i.e.: GSF Red) patients, nor do they deliver day-to-day GP care

Activity NOT related to EHCH should be directed to the patient's own surgery, as appropriate. You can access individual practice websites here.

Information for Relatives / Advocates

Further information about what the team will do for your relative is available via the link below.

Who Can Refer to EHCH

Any care home member of staff -Clinicians in a patient's own GP surgery (GPs, PAs, ACPs) - where there is a specific need (i.e.: for non-acute advanced planning)

Who Should Be Referred to EHCH

All new and permanent residents - Any residents of concern

How to Refer:- EHCH Team - Southport (Southport patients only)

  • For NEW PATIENT referrals, complete a care home referral form and return it via secure e-mail to the relevant team. 
  • For RESIDENT OF CONCERN, complete a resident of concern referral form and return it via secure e-mail to the relevant team.
    -Ensure to provide as much relevant information as possible, including clinical observations. 
  • We will accept referrals from the patient's own GP surgery, provided this is clinician-initiated for a specific issue. Primary care clinician referrals:- e-mail the relevant team. N.B. This is not an acute response service

Contact Us:
Monday-Friday, 9am - 5pm
01704 395807

Referral / Contact email: sfhealth.carecoordinator@nhs.net

How to Refer:- EHCH Team - Formby (Formby patients only)

  • For NEW PATIENT referrals, complete a care home referral form and return it via secure e-mail to the relevant team. 
  • For RESIDENT OF CONCERN, complete a resident of concern referral form and return it via secure e-mail to the relevant team.
  • We will accept referrals from the patient's own GP surgery, provided this is clinician-initiated for a specific issue. Primary care clinician referrals:- e-mail the relevant team. N.B. This is not an acute response service

Contact Us:
Monday-Friday, 9am - 5pm
01704 835155

Referral / Contact email: formby.carehometeam@nhs.net 

Useful Resources - for patients, relatives & homes

Medication Information & Emergency Prescription Requests - for homes

Acute/Emergency Symptoms: When To Call 999 - for homes

Acute Referrals - for homes

2-Hour Urgent Community Response (Visiting Service) (GTD)

  • Homes can refer any acutely unwell patients (excluding end of life) who do not need an ambulance
  • The service offers: Advice, assessment and home visits
  • 7 days per week: 8am - 6:30pm
  • Remember: Have a full set of observations available for the clinician to triage (see online training section, below)
  • Further information is available here

Care/Nursing Home Direct Referral Line

2-Hour Urgent Community Response (Visiting Service) (GTD): 07738837779

2-Hour Urgent Community Response (Merseycare)

Homes must refer all patients with any of the conditions below directly to the 2-hour UCR service, not the usual GP. Referrals can be made by any health or social care staff member where there is/has been any of the following:

  • Fall - no SERIOUS injury, fracture or loss of consciousness
  • Increased frailty - sudden loss of mobility or independence due to an event, such as infection
  • Reduced function or mobility - sudden or gradual change in being able to cope with daily living
  • End of life crisis support - where core services are not available to offer symptom control or pain relief
  • Urgent equipment provision - equipment needed to support function and to keep the patient safe
  • Confusion or delerium - increased or new confusion, including worsening dementia
  • Urgent catheter care - blocked catheter or pain from a catheter-related issue
  • Urgent diabetes care - when at risk of hospital admission or for a blood sugar measurement concern

Clinical Observations: Undertaking observations can be vital. These include: breathing rate, pulse, peripheral oxygen saturation, blood pressure, temperature and level of alertness. You will find instructions in the 'online training for community and care home staff' section, below.

Care/Nursing Home Direct Referral Line

2-Hour Urgent Community Response (Merseycare) Referral line: 0300 323 0240 and select option 1

Routine Referrals - for homes

Referral - Other - for homes

Requesting Proxy Access to Online Records

Homes can request proxy access to records, with a resident's permission. This is via the practice and it enables access to:-

  • Ordering medication from the GP surgery
  • Viewing drug allergies and sensitivities
  • Seeing a list of immunisations
  • Viewing test results
  • Accessing past medical history
  • Seeing letters - such as discharge summaries, outpatient follow-up letters, EHCH reviews, EHCH proactive clinical support plans (PCSPs)

Further information is available here.

Online Access to Records

Homes can register for NHS App proxy access. From here, you will be able to view GP records, including EHCH face-to-face reviews and copies of important documents such as proactive clinical support plans (PCSPs). You will also be able to request routine repeat medication from the patient's GP surgery.

NHS Mail Account Access for Homes

The EHCH team must have secure e-mail communication with homes. NHSmail is available to all domiciliary, residential or nursing care providers regardless of whether they support local authority, NHS or self-funded individuals. 

The Importance of Enhancing Health in Care Homes

The NHS long term plan is committed to providing the framework for enhanced health in care homes

The guide for care-homes may be of particular use to you / your team and can be accessed here.

The video links below highlight how we can work together for better care - learning from the EHCH vanguards.

 

 

 

Online Training for Community and Care Home Staff

A series of short videos (around 3 minutes each) describe how to take measurements from residents correctly (such as blood pressure and oxygen saturation), spot the soft signs of deterioration, and prevent the spread of infection.

These videos include:

1) Introduction to sepsis and serious illness

 

 

2) Prevent the spread of infection

 

 

3) Soft signs of deterioration

 

 

4) NEWS what is it?

 

 

5) Measuring the respiratory rate

 

 

6) Measuring oxygen saturation

 

 

7) Measuring blood pressure

 

 

8) Measuring heart rate

 

 

9) Measuring level of alertness

 

 

10) How to measure temperature

 

 

11) Calculating and recording a NEWS score

 

 

12) Structured communication and escalation

 

 

13) Treatment escalation plans and resuscitation

 

 

14) Recognising deterioration in people with a learning disability

 

 

NEWS2 Scoring:

You may wish to use this online link to calculate a NEWS2 score. 

HYDRATION for Older People - Training & Resources

It is really important that older people are and remain adequately hydrated. 

This e-learning course link provides training for community carers (of any role or level) and gives an overview of the hydration needs for older people and how to support people to drink more. 

This course takes around 40 minutes to complete. 

PERSONALISED CARE - Resources

The personalised care institute (PCI) provides a range of extremely useful (and free) courses for health and care professionals, regardless of profession or seniority.

The training offered includes:

1) Core skills - level 1 - 1 hour

2) Shared decision making - level 3 - 1 hour

3) Personalised care and support planning (PCSP) - level 3 - 45 min

4) Remote Consultation e-learning - level 1 & 2 - 30 min

5) A range of PCI-endorsed courses.

All courses are available via this link.

 

*Information Below - For EHCH Staff Only*