Adult Community Nursing and Primary Care nursing working together to meet patients’ needs closer to home. Spotlight on the MY Integrated Care Team

Revised Adult Community Nursing Specification ACN working collaboratively with primary care nurses, GP’s and practice managers. Implementation of the ACN action plan. Patients being seen in the most appropriate place. Teaching patients, carers and relatives to self-care.

Housebound – principle “A housebound patient is an individual who is unable (at the time care is required) to leave their home environment due to a physical or psychological illness and to whom a GP would normally offer home visits as the only practical means of enabling face-to-face consultation”. An individual is not housebound if they are: “able to leave their home environment with minimal assistance and routinely undertakes unassisted visits or visits minimally assisted by family, friends or other helpers, for example, the Doctor, Dentist, Hairdresser, Supermarket and leisure venues”.

Adult Community Nursing Clinics Longer term supportive care for patients with complex needs/multiple morbidities in a clinic setting only for the following: (a standard operating procedure will be written for clinics) Complex wounds/leg ulcers and compression bandaging Chest/wound drain management Disconnection of chemotherapy and management of lines/syringe drivers Catheter care Doppler scans Primary Care Nursing Long term condition management ANP’s- see acutely unwell patients homes/clinics and care homes Clinics- Acute/ simple wounds, Imm and Vac, sexual health

MY Integrated Care Team (ICT) Who is in the Team? We are a team of nurses, therapists and health care support workers who provide care and support patients in the community preventing hospital admissions and facilitating early discharges. The team consists of: Band 7Team Leader Band WTE – co-ordinators, triage, reassessment, allocation Band WTE – community staff nurses Band 4HCSW Co-ordinator, allocation of HCSW visits HCSW’s 40 Nursing and therapy – rehabilitation, personal cares

What service do we provide? Provide a short term time limited service to people over the age of 18 with an acute health need, this includes ongoing assessment, rehabilitation, IV Therapy, Palliative Care at Home and review to ensure timely discharge. These conditions include, but are not limited to chest infections, UTI’s, fractures, medication support, reduced mobility. The future model will see the team working proactively to facilitate patients early discharge from hospital. Following referral the nurse/therapist visits the patient and performs a holistic assessment in their home and decides with the patient what support is required.

Palliative Care at Home Patients who are in their last 6 weeks of life with a health need (End of Life) The patients can be referred by the hospital, GP, hospice or District Nurse.

Out of Hours The service is 24 hours per day and is staffed by RN’s and HCSW’s for the night shift, from 17:30 hours to 08:00 hours. The Out of Hours service visit patients who have planned and unplanned needs and all the Wakefield District urgent calls. These will include urgent calls for blocked/expelled catheters, stat doses for controlled drugs, syringe drivers and dressings.

IV therapy at Home The team provide community IV Therapy and subcutaneous fluids to patients in their own home/clinics/care homes. The nurses are trained in IV Therapy and cannulation. Any patients receiving IV Therapy will be assessed for suitability for administration at home and subcutaneous fluids. The team work closely with the consultant microbiologist ensuring patients are on the correct treatment regime and dosage. Treatment varies from a short term to long term therapy.

REFERRALS TO THE SERVICE FOR IV THERAPY

Source of referral and conditions treated Source of referralConditions treated

Patient testimony I have been a patient receiving daily care from the IV team since 24 th December I have nothing but the highest praise for all the staff who have visited me. They are so professional, kind, caring and nothing is too much trouble. It has been nearly 6 months of daily visits now. I am so very grateful to everyone for all your care and it is with heartfelt gratitude that I am writing this feedback. With grateful thanks.

ons Questions ??????