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?