The majority of people in Oxfordshire’s care homes have dementia and many have co-existing physical or mental health needs. Recognition of this full range of complex needs can be difficult for the largely untrained workforce in care homes that often struggle to bring together the physical and the mental aspects of care. This contributes to some inappropriate admissions to homes when people could continue to live in their own community, high admission rates to hospital services and a high level of Delayed Transfer of Care out of the acute hospital. There are existing inreach teams focussing on falls prevention, pharmacy liaison, or mental health teams but each operates separately, and responds only for specific elements of need, and training is not linked, which is inefficient and inconsistent as a result.
The project will explore whether combining the expertise of pharmacy, primary care and community mental health team staff in a single in-reach team improve the physical and mental health of residents of care homes.