- Builds patient confidence in their own environment
- Reduces the risk of falls and losing muscle strength
- Less risk of catching healthcare acquired infections
- Enables tailored care plans
- Eases the transition from hospital to home
Last year this model was introduced in the Nicol Unit at Stratford upon Avon Hospital. Although we reduced the number of beds we were actually able to treat more patients through better use of beds and enhanced and expanded services in the community.
What does the community team do?
The team work with patients who are over 18 years old to offer care in the patient’s own home. This group of patients require support from health care professionals but it is not appropriate for them to be in the acute setting. The team also work to facilitate ‘early supported discharge’ where patients can return home from the hospital setting when they no longer require acute medical care. They also help with ‘admission prevention’ by working closely with GPs and Community/Specialist nursing to enable patients to recover at home, for example, patients with chest or kidney infections.
The team responds 7 days a week from 8.30am to 10pm. At any one time the team may be supporting 30 patients to stay at home by working with them daily. The team respond to patients within two hours and conduct short-term assessment within three days in order to establish a suitable pathway for each patient. This may include referral to social services or a financial assessment if they have ongoing social care needs.
The team also offers rehabilitation to regain confidence and strength with daily living tasks that are necessary to remain living at home, for example, mobilising indoors, managing their stairs, maintaining personal care or preparing meals and drinks.
What staff are in the team?
Team members include rehabilitation assistants, nurses, occupational therapists and physiotherapists. At any one time there may be 30 people working intensively to enable patients to remain living in their own home.
What are the aims of the team?
The team aims to reduce rising emergency admissions for people aged 65+ and reduce hospital length of stay for this group. There are many benefits to this, including preventing loss of strength and confidence. This team also aims to integrate services across acute, community, GPs, social services and other organisations, for example Age UK. These processes will ensure that only people who require hospital care will be in the hospital setting.
Patients have responded very positively to these changes in Stratford:
Patient Comment about care at home from the community team “My husband became ill and it was very worrying, the nurse came and examined him. She worked with the out of hours GP and I found nothing but help, kindness, understanding and reassurance. Thank you it is such a comfort to know you are there if we ever needed you again.”
This new model in Shipston on Stour has already improved care with more patients being discharged from hospital to their own homes with continued rehab and suppot at home.
The Day Unit at Ellen Badger is also changing in line with this new medical model and has been renamed to an ‘Assessment and Rehabilitation Centre’, refocusing care for patients and reflecting a new approach to rehabilitation.
Ian Philp, Medical Director at South Warwickshire NHS Foundation Trust said: “I am delighted to see that the lessons we learnt on the Nicol Unit in Stratford upon Avon, to improve services for local people, are being transferred to Shipston. I am looking forward to working closely with colleagues at Ellen Badger Hospital and GPs in Shipston to improve services for patients.”
Dr Daniel, GP, Shipston Medical Centre said: “This is a really positive change in the way we provide medical care at the Ellen Badger Hospital that will improve quality of care provided, benefiting the local and wider community.
“We now have two doctors providing all the medical cover with daily ward rounds improving both continuity and communication. We also plan to increase the medical services we offer at the Ellen Badger Hospital, such as intravenous treatments and blood transfusion in certain circumstances. This will allow us, the local GPs and nurses, to treat more patients closer to home and the closer links with community services this will enable a quicker supported discharge home for inpatients.”
Notes to editors:
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