ACCESS TO COMMUNITY SERVICES FOR HAMMERSMITH & FULHAM WINTER 2017/18

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1 TYPE OF SERVICE SERVICE NAME AND DESCRIPTION OPENING TIMES CONTACT DETAILS RAPID RESPONSE CLINICAL INTERVENTION & PREVENTATIVE RE- ABLEMENT REHABILITION & RE- ABLEMENT CIS delivers unplanned care to patients. It supports acute illness in the community when it is safe and appropriate to do so Response within 2 hours of acceptance of referral Treatment for 5 days Includes CIS Liaison - working within A&E departments and pre admission units to determine if people can be better supported at home or by other non- emergency services rather than through hospital admission. Both rehabilitation and reablement are offered for up to 6 weeks. Rehabilitation provides physical and occupational therapies for housebound people to enable them to achieve functional goals and improve their independence. Reablement services are provided in the home to help a person gain confidence and re-learn the skills to carry out daily activities and practical tasks. Response within 24 hours Commence treatment within 2 days of patient being ready for service (subject to waiting lists at go-live) Mon-Sun 8-8pm, 7 days a week Single Point of Referral number is cis.3borough@nhs.net Patients often have a combination of needs; at the time of referral one need may predominate but upon completion of the initial episode of care the patient may benefit from continuing with CIS to progress their independence i.e. moving from the Rapid Response pathway to the Rehabilitation. 1

2 CIS Reablement; For those who have goals to achieve to live a more independent lives. Reablement offers support for patients to regain confidence with activities in the kitchen, with personal care, and any other domestic tasks. Community Independence Assistants (CIAs) will also work with people to help them to gain confidence out of homes, shopping, and with social inclusion. This is a free service for up to 6 weeks, you will need to have goals to achieve to be eligible for this service. If ongoing needs are identified CIAs will refer the patient for long term domestic support, and make sure this is in place before pulling out. Reablement support is a 7 day, 365 days a year service. It operates between 8 am 8 pm, Team doesn t take emergency referrals, Referrals have to be made via the SPOR : Mon Fri ; 9-5 CIS ASC Therapy: This is a team of OTs and Independent Living Assessors + SW, to assess and provide equipment or minor adaptations in people s home to enable them to continue living independently. This team works very closely with the Reablement team, and make sure goals are achieved through OT, equipment and reablement input. Referrals via: SPOR COMMUNITY NURSING District Nursing Service single point of Access (SPA) for all referrals. Housebound patients only. Response time 2 Monday to Friday: 9.00am to 5.00pm daily E-Fax: clcht.spa.referral@nhs.net General Queries only:

3 Unplanned: 24 hours Routine: 72 hours to make contact visit within 7 days Planned: 72 hours to make contact visit within 4 weeks Out of Hours District Nursing Service for housebound patients only. Sat-Sun + Public Holidays Mon-Fri outside core hours of DENTAL Emergency Dental Service 7 days a week + Public Holidays: 24 hours Clinician Only: General Queries: SPA Out-of-Hours T: / 111 Phone: 111 3

4 GP GP Out of Hours Service where a health care professional needs to speak directly to an Out of Hours GP. (Not for use by the public who need to phone 111.) In December, Friday 22nd and Friday 29th December 2016 are normal working days. The expectation is that practices are open from 08:00 to 18:30 unless alternative arrangements are agreed in advance. Sat-Sun + Public Holidays Mon-Fri outside core hours of Phone: Weekend Plus Service Bookable planned care appointments across 3 Practice locations (Parkview Practice, Brook Green Medical Centre & Cassidy Medical Centre). The 111/GP Out of Hours service is also able to book emergency appointments in directly at the hubs (1 appointment available per hour). Monday Friday all three practices offer GP appointments between 18:30 to 20:00. *Saturday Opening: Parkview: 9:00 17:30 Brook Green Medical Centre: 08:00 20:00 Cassidy Centre: 9:00 15:00 Sat and Sunday* + Public Holidays** Mon-Fri outside core hours of Bypass numbers: Brook Green Medical Centre: Cassidy: Parkview Centre for Health and Wellbeing: *Sunday Opening: Parkview: 09:00 13:00 Brook Green Medical Centre: 08:00 20:00 Cassidy Centre: 09:00-15:00 **Public Holidays: Cassidy Medical Centre & Parkview Practice will be the only Practice hubs open for the delivery of urgent walk in care. In December, these two hubs (Parkview Practice and Cassidy Medical Centre) will be open on the Bank Holidays (25/12 26/12 & 01/01/2018) from 09:00 to 15:30. 4

5 MENTAL HEALTH Mental Health Single Point of Access. SPA - A telephone based service which manages all adult mental health referrals as well as providing telephone support to patients and carers 24/7 365 days a year Crisis Resolution & Team The Hammersmith and Fulham crisis resolution team (CRT) provides a safe and effective home based treatment service for people who are experiencing a mental health crisis of a nature or degree that would normally require admission into hospital. These are accessed by the SPA 24/7 SPA including bank holidays Mon-Fri 9-5 (not bank holidays) Mental Health Single Point of Access Tel: Liaison Psychiatry Service available at Charing Cross and Hammersmith Hospital for patients presenting in an emergency or mental health crisis or who are currently an inpatient. Referral via A&E/ hospital clinician. CHX: HH: Cognitive Impairment and Dementia (CID) Service - assessment and treatment for people who live in the London Borough of Hammersmith & Fulham who experience problems with their mental abilities, such as thinking, knowing and remembering. Tel: Fax: Child & Adolescent Mental Health Service providing mental health assessment and treatment for children, young people and their families living within the boroughs and Hammersmith & Fulham, up to their 18 th birthday. Referral via GP of health and social professional. If your referral is urgent or you need to discuss a case with a senior clinician, please call (Mon-Fri, 9am-5pm). Mon-Fri 9-5 Tel: Eating disorders Eating disorders are covered by a single team based in Ealing. We offer assessment and treatment to young people under 18 years who are registered with a GP in the boroughs of Ealing, Hounslow and Hammersmith & Fulham Mon-Fri 9-5 Tel:

6 who have anorexia nervosa and bulimia nervosa. We also accept self-referrals directly to CAMHS. PHARMACY Please see pharmacy opening hours in the spread sheet attached. PHARMACY URGENT REPEAT MEDICINES The purpose of the Pharmacy Urgent Repeat Medicines (PURM) Service is to facilitate appropriate access to repeat medication Out of Hours (OOH), enabling patients to access an urgent supply of their regular prescription medicines when appropriate. Phone: 111 Patients will be referred to a participating pharmacy by NHS111 to access the service. This service will allow the supply of a medicine at NHS expense where the pharmacist deems that the patient has immediate need for the medicine and that it is impractical to obtain a prescription without undue delay. 6

7 TYPE OF SERVICE SERVICE NAME AND DESCRIPTION OPENING TIMES CONTACT DETAILS SOCIAL SERVICES Adult Social Care Information & Advice Team Response times are dependent on prioritisation against nature of presenting need and other priorities, and the urgency of the referral. Team will provide advice information, will take referrals for social care, they will also provide support for informal carers. Team is able to put in emergency care packages to avoid hospital admissions. Mon-Fri: :00-9:00 AM H&F Advice: Phone: Fax: Walk-in: King St, Hammersmith has relevant documentation. URGENT CARE EMERGENCY DUTY TEAM The Hammersmith & Fulham Council EDT Team will only respond to emergencies. Other service requests will be logged for a response during next weekday office hours. For unscheduled hospital discharges out of office hours, the hospital may directly request to Domiciliary Care Agencies to restart suspended existing packages of care. This is subject to the Agency being able to facilitate a restart. For assessment of urgent symptoms that are not believed to be life-threatening. 7 days a week + Public Holidays: 24 hours EDT: NB For out-of-hours emergencies, please contact the Duty Team on Phone: days a week + Public Holidays, 24 hours/day Hammersmith Urgent Care Centre Interim Intermediate Health and Social Care beds & Interim Intermediate To support timely hospital discharges for patients who are medically optimised and do not require an acute bed but are unable to return home either for rehab or step-down care at home. Access to these interim beds is for hospital discharges only and Mon-Fri Sat-Sun Closed on Public Holidays All units are open 7 days a week + Public Holidays, 24 hours/day Walk-in: Parsons Green Centre 7

8 Rehabilitation Beds referrals are made via the Acute Hospital Discharge Teams based at Imperial hospital sites and Chelsea and Westminster Hospital. Intermediate Interim Rehabilitation Beds -x22 beds at Athlone and x11 beds at Alexander Unit Criteria: 4 week stay on average Athlone provides general and specialist level 3 stroke rehab currently on 5 days/week basis Both units provide rehab for orthopaedic patients who may initially be non-weight bearing following fractures or surgical procedures Patients benefit from MDT intervention Require adequate cognitive function to understand goals and follow instructions and hence benefit from rehab intervention. Patient must have capacity and agree to rehab referral Requires a level of nursing input alongside need for bed based rehabilitation Exclusions: People with severe mental health issues/challenging behaviour that is not conducive to the rehabilitation environment Interim Intermediate Care beds - x 21 beds at Farm Lane Nursing Home Maximum stay of 4 weeks Pressure ulcers of grade 2 or below. Grade 3 or above pressure ulcers on a case by case basis, Patients requiring supervision/assist of 1 or 2 Require care package, equipment, adaptions Require HNA/DST for placement decisions and where currently home of choice not available Athlone and Alex Rehab beds CLCH SPOR CLCH.SPA.Referral@nhs.net Farm Lane Care UK SPOR f.nursinghome@nhs.net 8

9 Require short period of time to ensure safe planning and provision of complex care at home Those with a long term feeding plan and non-complex feeding regime e.g. PEG feeds Those on long-term oxygen Exclusions: Those requiring bedded rehabilitation Those with complex challenging behaviour needs x8 Interim Intermediate Health (D2A) beds - Garside Nursing Home Criteria: CHC Checklist positive Medically optimised Period of recuperation Assessment of long term needs Home of choice not available Complex Tissue Viability needs including ungradeable pressure ulcers Requires nursing care and hoist with 2 carers Garside Home Manager: febin.arifsadhat@sanctuary-housing.co.uk Exclusions: Those with challenging behaviours Those with Dementia who are prone to wandering Those with hyperactive delirium Those with specialist tracheostomy needs and/or requiring mechanical ventilation Those who require rehab Clients with purely social issues x10 Interim Intermediate Adult Social Care Residential - Norton House 9 Norton House Home Manager:

10 Criteria: Over 60 Requires emergency placement, no more than 6 weeks from day of admission Residential care needs Has an identified keyworker/sw Felicia.Imafidon@anchor.org.uk Joanna.Krokos@anchor.org Exclusions: No health needs other than those that can be supported by DN No formal diagnosis of Dementia x7-10 Interim Intermediate Care beds - Acton Care Centre For Imperial Patients Only Criteria CHC Checklist positive 4 week maximum length of stay Primary need for nursing level care Pressure ulcer care grade 2. Grade 3 or above to be considered on a case by case basis Clients requiring nursing care of 2 staff Falls management Early dementia without significant behavioural issues Acton Care Centre JasmineP@goldcarehomes.com Exclusions: Clients with challenging behaviour Clients with social housing needs 10