Cambridge City 4 Care Homes Team Development Project

Cambridge City 4 Primary Care Network

Project summary

The Cambridge City 4 Primary Care Network (CC4 PCN) Care Home Team was established in April 2025 to improve care for some of the NHS's most vulnerable patients. Care home residents frequently live with severe frailty, multiple long term conditions, polypharmacy and complex health and social care needs. Historically, care was often fragmented across organisations, resulting in reactive management, duplication of work and avoidable deterioration and hospital admissions.

To address this, CC4 PCN developed an innovative multidisciplinary Care Home Team serving five care homes across the network. The service combines an Advanced Pharmacist Practitioner/ Clinical Pharmacist, a Paramedic Practitioner, a Pharmacy Technician who is also a Physician Associate, support from Pharmacy Technicians from the networks Pharmacy Teams, Operational and Development Leads, PCN Manager and GP oversight from the Clinical Director of the PCN. The team works in close partnership with the dedicated care home Geriatrician Team (the Enrich team) at Addenbrooke's Hospital, creating a unique interface between primary care, secondary care and care homes.

Unlike traditional models that rely on reactive responses to emerging problems, the team provides proactive, resident centred care through regular ward rounds, multidisciplinary meetings, comprehensive new resident assessments, structured medication reviews, frailty assessments, advance care planning, medicines optimisation and end of life support. The team also provides education and ongoing support for care home staff, helping to improve confidence, clinical knowledge and quality of care.

A key innovation is the direct relationship between the Care Home Team and Care Homes themselves. Rather than operating solely through individual GP practices, the team acts as a single point of contact for residents, families and care home staff, enabling concerns to be identified and addressed early before escalation to emergency or hospital based care.

The service demonstrates how medicines optimisation can be embedded within a broader frailty focused model of care. Through multidisciplinary working, shared decision making and proactive intervention, residents receive more holistic, coordinated and person centred care. The model strengthens communication across organisational boundaries, supports appropriate prescribing, reduces medicines related harm and promotes care aligned with residents' wishes.

To our knowledge, this combination of advanced pharmacy practice, paramedic expertise, physician associate skills, GP oversight and dedicated geriatrician collaboration within a single Care Home service is unique within Cambridgeshire. The model is scalable, transferable and has the potential to be replicated nationally to improve outcomes for care home residents whilst supporting more efficient use of NHS resources.