Buurtzorg Model of Care in Tower Hamlets: Developing a new and innovative approach to patient-centered care

Buurtzorg Model of Care in Tower Hamlets: Developing a new and innovative approach to patient-centered care

Introduction

It’s an exciting time for health and social care staff working in Tower Hamlets. As part of our Tower Hamlets Together partnership, we are about to embark on a pilot to explore new and innovative ways of providing the very best community nursing care to the people we serve.

Based on a model of care from the Netherlands (known as the Buurtzorg model), we are about to establish our first ‘self-managed’ teams of nurses who will deliver dedicated personal, social and health care to patients in a small area of Tower Hamlets. The team will work collaboratively with formal and informal networks to ensure provision of holistic patient-centered care that promotes self-management, patient engagement and improves overall patient and staff satisfaction.  

What is a ‘self-managed’ nursing team?

The new self-managed nursing teams will be much smaller than existing community nursing teams, serving a much smaller caseload with more professional freedom on how care will be provided to their patients. Based around the patient lists of specific GP Practices and working as part of a multi-disciplinary team (MDT), the Buurtzorg nurses will be responsible for managing their own workflow. They will also manage their own budget and professional development, with support from a Coach who will facilitate team development, and promote a solution focused approach. The team will even seek its own office accommodation and decide on the furniture!

The teams will be responsible for:

  • Designing and delivering individualised patient care plans including personal, domiciliary and nursing care tailored to patients’ needs    
  • Collecting, reporting, maintaining and sharing patient information for healthcare delivery purposes.  
  • Agreeing with the patient or their representative about the care they receive
  • Caring according to the professional norms including professional values and behaviours e.g. Nursing and Midwifery Council (NMC) Code of Professional Conduct 
  • Assessing, coordinating, and evaluating the professional and social network with the client
  • Continuously evaluating the care and adjusting to any newly identified needs.  

Care will be provided to patients within a small geographical footprint between the hours of 8am to 8pm daily, 365 days a year. One nurse will be on call from 8pm to 8am, triaging calls from patients on their caseload and providing support. Should there be a need to visit the patient, the Tower Hamlets out-of-hours nurses will visit the patient and document care provided as necessary.

The nursing team will review their caseload daily, identifying the needs of their patients and the team composition, using the skillset in the team to determine who is best placed to provide care to the patient.

As part of orientation, the team will visit the Netherlands for a week to understudy the Buurtzorg Nurses.

How will this benefit patients?

Nurses will provide holistic patient-centered care that focuses on the patient’s needs, including personal care. This will help reduce the prevalence of conditions such as pressure ulcers and prevent unnecessary/unplanned hospital admissions for those with a long-term condition by early identification and intervention. It will also ensure that the patient only has to tell their story once, and help reduce duplication of care and improve communication.

This way of working will promote self-managed, outcomes-based care that supports patients to reach their maximum potential, therefore helping to tackle health inequalities in the area

The outcome of this pilot will help to shape the development of community services across other parts of Tower Hamlets in the future.

What are the timescales?

We are aiming for the first pilot to launch on 1 January 2017 which will last for one year. In preparation for this we are currently seeking to recruit nurses to become part of the first self-managed nursing team in Tower Hamlets.

Throughout the pilot we will be undertaking various forms of evaluation to establish the impact of the new approach on patient care; both in terms of their experience of the service and health outcomes, as well as identifying benefits for staff.

Where can I find more information?

We are holding two information events for anyone interested in finding out more about becoming a Buurtzorg community nurse in Tower Hamlets. These will be held on:

  • Tuesday 22 November from 12 noon to 1.30pm
  • Wednesday 23 November from 3pm to 4:30pm​​​​​

Both events are being held at the Education Academy, Mile End Hospital, Bancroft road, London E1 4DG. Please note you only need to attend one event as they include the same content.  

For more information and to confirm your attendance at one of the information events, please contact Caroline Ogunsola, Service Transformation Lead at East London NHS Foundation Trust on 07901 001 092 or email caroline.ogunsola@bartshealth.nhs.uk