Community Integrated Teams - West Locality Susie Morvan & Sue - PowerPoint PPT Presentation

Community Integrated Teams - West Locality Susie Morvan & Sue Martin Clinical Operations Managers

Integrated team members The integrated community team comprises of: • Clinical Leads • Community Nurses • Healthcare Assistants / Assistant Practitioners • Community Physiotherapists, Occupational Therapists and Assistant Practitioners • Community Matrons

Community Nursing Overview of service; • Commissioned 7 day service to meet the nursing needs of housebound patients in the community. • Interventions may include a range of the following: • Skin care, wound care, palliative care, venepuncture, injections (B12/ Flu Vaccinations), admission avoidance, assessing continence needs and referring on, health promotion, providing nursing support for patients and carers, Leg Ulcer Clinics

Aims of the Community Nursing Service • Support patients in their own home (housebound) within West Norfolk & Upwell HC • Support Residential Care homes within West Norfolk & Upwell • Avoid unnecessary hospital admissions • Facilitate earlier discharge from acute care • Enable patients to return home from another place of care as soon as possible

Community Therapy Overview of service; 5 day service to meet the therapeutic needs of patients in a variety of settings including; • Community Hospital • Spot Purchase Beds • Intermediate Care Beds. Interventions may include: Rehabilitation Programmes, Falls Prevention, Moving & Handling assessment, Admission Avoidance, Equipment Assessment, Home Visits, Palliative Care, Gait Assessments and provision of walking aids.

Community Matron Overview of service • 7 day service to meet the nursing needs of housebound patients in the community. • Primary focus on admission avoidance. • Case management of complex nursing issues in the community. Liaison with GP’s, community nurses, therapists, social services & care agencies. • Range of nursing interventions provided as required. • Able to admit to spot purchase/community beds if appropriate.

Referral Criteria and Sources:- • Patients who are aged 16 or over. • Patients who are housebound or where their needs are best accommodated within the home setting i.e. specialist therapies, continence care. • Palliative care and end of life patients. • Referrals taken from all Healthcare Professionals as well as the ability for the patient to self referral

Point of Referral and working practice:- • Single Point of Referral via West Locality Hub (call may be answered elsewhere) – 01553 668777 • Patient’s Triaged and allocated to the appropriate team • The teams work in clusters aligned to GP group practices for continuity of care (Kings Lynn) • Each cluster group consists of a Community Matron, Band 6 nurse, Band 5 nurses, HCA’s (Kings Lynn) • Registered Nurse linked to GP surgery to attend MDT meetings

Integrated working • Co-location of team members • Joint visits as required • Shared team meetings & training • Understanding of roles, competencies and areas of overlap • Close working relationship with equipment provider NRS • Networking with wider team – GP’s, social services, mental health, housing, assistive technology. • Whole Systems Approach • Independent Providers of Care and the Third Sector

Any Questions?