Information for patients

Transcription

1 Information for patients HRCH Single Point of Access Single Point of Access is a one stop referral system for patients residing in the London Borough of Hounslow and Richmond for the following services: Phone: Fax: /61 hounslowandrichmond.spa@nhs.net Open Monday - Sunday 07:00 19:00 Patients referred will be assessed by a member of the below teams and a treatment programme will be provided as clinically indicated. Combined Services Adult Community Nursing Services Including Night Nurses & IV Nurse Provide services to Hounslow and Richmond residents aged 18+ who are housebound requiring active nursing treatment to promote recovery, prevent further deterioration or loss of function from a specific condition or intervention within the community. Patients who require nursing intervention and are independently mobile are to attend the treatment room. Main conditions treated include: Palliative care, diabetes management, long term intravenous therapy, continence, wound care, leg ulcer treatment, catheter care, enteral feeding and long-term conditions. Community Matrons Including Keep Well Nurse Prevention of admission to patients at risk of inappropriate hospital admissions. Advanced assessment for acute onset of chronic conditions. Dehydration and pain assessments Provision of medical equipment where nursing intervention is required -e.g. nebulisers, nursing beds and walking aids. Case management and Chronic disease management- e.g. Respiratory, O2 therapy, MS,PD and CHD

2 Tissue Viability The tissue viability team offers treatment for complex wound management: Complex wound/leg ulcer clinics in the community Education and training Prevention and treatment for pressure ulcers Treatment in leg ulcer management Audit Wound care guidelines and policy provision Advise on the provision of specialist pressure relieving equipment Advice is also offered on wound technology products Negative pressure wound therapy Continence Service To act as an advisory service on bladder and bowel care for all clients and health care professionals with in Hounslow Community Healthcare. To carry out a comprehensive Continence Assessment for all clients that are not known to the District Nursing Service in both in a clinic and community setting. To carry out regular reviews and reassessments. To treat in line with National Guidance following this assessment. Provision of joint Continence Specialist Nurse and Consultant Physiotherapy clinics. To support patients with treatment regimes such as bladder retraining, pelvic floor treatments and teach and support clients carrying out ISC (Intermittent self catheterisation). Training special needs children with toileting skills and promoting life style changes To provide products to clients in their own homes following a full continence assessment and if it is felt to be the most appropriate action. Multiple Sclerosis Nurse Specialist The MS Specialist Nurse provides an essential and holistic link between the person with multiple sclerosis (MS), community or social services and their consultant and GP. The nurse provides specialist therapeutic and practical support to people with MS, their families or carers at the time they need it most. The MS Specialist Nurse provides a pivotal role in co-ordinating the activities of all health professionals involved in the care of people with MS. The MS Specialist Nurse is a community based nurse who has received specialist training in the management of multiple sclerosis and is linked into regional and national networks of the UK Multiple Sclerosis Specialist Nurse Association (UKMSSNA) to ensure an up to date knowledge of best practice in the field.

3 The MS Specialist Nurse provides: Support and information for patients who have recently been diagnosed with MS Ongoing support for patients with MS and their carers via telephone, clinics or home visits Specialist nursing assessment and advice on the management of MS Case finding for specialist disease modifying treatments Information and monitoring of prescribed disease modifying medications, when required Link between community and acute, outpatient or specialist tertiary care setting Case management for patients with complex needs Links to other services supporting people with MS, making referrals when required Education and training for those involved in MS Parkinson s Disease Specialist Nurse The Parkinson's disease Specialist Nurse is a community-based nurse with specialist knowledge of all aspects of the condition. She works within the Neuro-rehab team and is linked into regional and national networks of the Parkinson s Nurse Specialist Association (PDNSA) to ensure up to date knowledge and best practice in the field. She also works closely with the Neurologist at West Middlesex University Hospital. The role includes: Support and information for patients who have recently been diagnosed with PD Ongoing support for patients with PD and their carers via telephone, clinics or home visits Specialist nursing assessment and advice on the management of PD Case finding for specialist disease modifying treatments Information and monitoring of prescribed disease modifying medications, when required Link between community and acute, outpatient or specialist tertiary care setting Case management for patients with complex needs Links to other services supporting people with PD, making referrals when required Education and training for those involved with PD Cardiac Rehabilitation The Cardiac Rehabilitation service provides physiotherapeutic assessments of cardiac function and exercise ability. Phase 2 assessments are carried out with individual patients; and Phase 3 cardiac rehabilitation is delivered in groups. The aim of the service is to: Assess cardiac function and exercise ability Educate patients in how to manage their condition and exercise safely Provide an optimum exercise programme appropriate to individual need.

4 Hounslow Services Community Phlebotomy Service Provide services to Hounslow residents aged 18+ who are housebound however require a blood test Continuing Care Team Providing specialist nursing assessments for patients needing care and being potentially eligible for NHS funding Community Recovery Service Includes Neuro-Rehabilitation Team Providing multidisciplinary Rehabilitation, prevention of admission and facilitation of discharge services. The service is operating the following caseloads & localities: Rapid Response (in liaison with Nurse Assessors) West Team Central Team East Team Mobility Clinic (Heart of Hounslow & Chiswick HC) Providing multidisciplinary rehabilitation and facilitation of discharge for people with neurological conditions. The service is operating the following caseloads & localities: Stroke rehabilitation Multiple Sclerosis specialist nursing & rehabilitation Parkinson s specialist nursing & rehabilitation Other Neuro-Rehabilitation (see list below) Integrated Community Response Team Patients must be: Registered with NHS Hounslow GP Over the age of 18 years including clients with a learning disability Admission avoidance criteria

5 Requires rapid assessment, intervention and / or rehabilitation within the patients chosen environment within two hours of receipt of referral following an immediate crisis and need for health intervention or breakdown of social care. Patient will attend accident and emergency or be admitted to hospital within 24 hours of identification of need by referrer without immediate intervention. Supported hospital discharge Patient has a significant change in status following deterioration of health condition or acute episode requiring intensive multi-disciplinary assessment and intervention to manage risk at the point of discharge and to maximise recovery and rehabilitation potential prior to transfer into core community services. The Integrated Community Response Team does not plan or facilitate discharge from hospital but will act on a consultative basis if there any blocks or gaps which are preventing early discharge. Assisted discharge from Hounslow Urgent Care Centre and West Middlesex University Hospital Emergency Department Requires rapid assessment, intervention and/or rehabilitation in accident and emergency within two hours of receipt of referral following an immediate crisis and need for health intervention or breakdown of social care to prevent admission. Patient will be admitted to hospital without immediate intervention. Speech and Language Therapy We are a team of Speech and Language Therapists with specialist knowledge in acquired neurological conditions, voice disorders and stammering. We work as part of the multi-disciplinary team directly with patients and carers offering a comprehensive range of inpatient and outpatient services (including a limited domiciliary service) for patients with communication and swallowing difficulties. We provide specialist assessment and management of patients who are registered with a Hounslow GP and present with communication difficulties such as dysarthria (slurred speech), aphasia (language impairment), apraxia (motor programming impairment), cognitive communication disorder, voice problems, stammering and/or dysphagia (difficulty swallowing). This could result from: Neurological conditions (including Stroke, Parkinson s, Multiple Sclerosis, Motor Neurone Disease, Huntington s, head injury, Dementia) Cancer (including brain tumour, head and neck cancer, oesophageal cancer) Respiratory conditions (including COPD) Gastroenterological conditions Where appropriate, we provide goal-led therapy programmes (e.g. direct therapy or communication groups), education, advice and support to family and carers, encouraging self-management.

6 We run an Aphasia support group called My Word and can refer onto other statutory and voluntary services, for example City Lit, the MNDA support group for carers and Integrated Neurological Services. Learning Disabilities The Community Learning Disability Team provides health and social care to adults who meet eligibility criteria and who live in the London Borough of Hounslow. The multidisciplinary team consists of the following health and social care professionals: Social workers Community learning disability nursing Dietician Physiotherapy (for people with profound and severe learning disabilities) Psychiatry Psychology Speech and Language Therapy Support for people with learning disabilities to lead healthy lifestyles Screening and early intervention designed to prevent the need for unplanned health or other services (including hospital admissions) Provide training (including bespoke) for families, statutory and 3rd sector organisations on supporting people with learning disabilities Assessments and Interventions Person-centred assessments including continuing health care assessments Mental health and psychological assessments and interventions Specialist nursing, speech and language therapy, dietetics and physiotherapy assessments and interventions relating to learning disabilities Assessment and interventions for people with behaviours that challenge Case Coordination Develop, monitor and review of personalised support plans and care packages Preparation of information for continuing care panels Liaison with statutory and 3rd sector organisations Family and Carer support To provide active advice to families and carers in support of people with learning disabilities as equal partners.

7 Richmond Services Richmond Response and Rehabilitation Team Including TMH Inpatient rehabilitation The Richmond Response and Rehabilitation team is an integrated health and social care service for adults, primarily older people, working in partnership with London Borough of Richmond Upon Thames Council. The service offers individual health and social care packages of support to help people regain their independence and wellbeing. The team can provide a range of short-term interventions including intensive therapy and practical support following a period of illness, disability or following hospital discharge. For people who have been admitted to hospital, the team will support a safe and timely discharge home or to a community setting. The team provides a rapid response to manage crisis and support people to stay at home, preventing unnecessary admission to an acute hospital or a residential/ nursing home. The team also supports early discharge services aimed at facilitating shorter periods of hospital stay including elective procedures/ admissions. The team is multi-disciplinary and includes: Nurses Occupational Therapists Physiotherapists Social Workers Mental Health Nurses Dietician Rehabilitation/Therapy Assistants Falls and Bone Health Service The integrated Falls and Bone Health Service aims to reduce the rate and risk of falls and fragility fractures amongst Richmond adults, and to improve the health and mobility of older people and sustain their independence. The service targets people who have had recurrent or occasional falls, those who feel at risk or afraid of falling and those aged 50+ for bone health management.

8 The service also provides education and training to healthcare professionals, social services and the voluntary sector on the best strategies for managing people who fall. The overall aim is to help stop people from falling in the future and reduce hip fractures and other injuries. If you are worried about falling, please visit your GP. If your GP is concerned that you may be at risk of a fall you will be referred to the Falls Prevention Clinic for a more detailed assessment Community Neuro Rehabilitation Including Speech and Language The Neuro-Rehabilitation team works with people aged 18 and above with acquired and long-term neurological conditions, helping them to achieve maximum independence in all aspects of daily life. The team works with clients in the most appropriate setting, either as an outpatient at Richmond Rehab Unit, in their own home or in the community e.g. gyms, day centres, and the workplace. The team aims: To provide a comprehensive, timely and specialist multi disciplinary rehabilitation service that is accessible to all neurologically impaired adults, empowering them to fulfil their maximum potential at whatever stage in their condition, with emphasis on function and quality of life. To assist in the on-going and end of life management of long-term conditions as part of the wider service in health and social services. The services provides for people with neurological impairment caused by, for example: stroke (CVA), traumatic brain injury, multiple sclerosis, Parkinson s disease, motor neurone disease. The service provides assessment, treatment and advice to clients and carers, regarding: Mobility, balance, posture, perception, domestic and self-care tasks Swallowing, eating, drinking, nutrition Communication speaking, understanding, reading, writing Memory, attention, emotional states, fatigue management Work, education and leisure Group work Parkinson s education group; general exercise group; fatigue management group; conversation groups. The service does not cater for people with mental health problems or learning difficulties as a main disability. Respiratory Care Team (Richmond) The Respiratory Care Team (RCT) provides specialist assessment and case management for patients with long-term respiratory problems.

9 Patients can be referred to the service via their GP or other healthcare professional. Referred patients receive a respiratory specialist assessment, which may result in changes to treatment to optimise their condition. Pulmonary Rehabilitation is run by the Respiratory Care Team at Teddington Memorial Hospital and Richmond Rehabilitation Unit. This is an exercise programme especially for patients with breathing problems to increase functional levels and manage breathlessness. The programme runs for six weeks and consists of exercise, education and relaxation sessions. The Respiratory Care Team also oversees home oxygen delivery within Richmond for respiratory patients and is able to assess and monitor patients on home oxygen via pulse oximetry or blood gases. Lymphoedema Service Lymphoedema is a lifelong condition for which there is no cure. It is a swelling of body tissue caused by failure of the lymphatic system: Offer a comprehensive Lyphoedema Specialist Practitioner led service for patients with Lymphoedema and Chronic oedema registered with a Richmond GP. Provide a comprehensive community based service for patients with Lymphoedema; with access to appropriate treatment nearer to their homes, hence avoiding hospital treatments and improving the patient s quality of life. Provide the highest quality treatment, advisory and support service to patients with chronic oedema, in order to prevent or delay complications of chronic oedema and prepare the patient for long-term independence. Maintain a close working relationship with GPs and other primary care staff. It will be a resource to promote the management of oedema, providing specialist advice and education to health care professionals commonly encountering this condition. Dementia Service Our Richmond community dementia clinical specialist service helps to promote independence at home and improve the service and quality of care for patients living with dementia and their carers. The Richmond community dementia clinical specialist service aims to improve communication and coordination of care by liaising with other services such as GPs, social services and other voluntary and statutory services.

10 Who is the service aimed at? Patients registered with a Richmond GP Carers of patients registered with a Richmond GP Those receiving care from other HRCH services What the service can offer: Home visits to assess and discuss your needs Dementia screening and referral to GP or memory clinic Recommendation and referral to local support services within the statutory and voluntary sectors Attendance at meetings with other professionals as your patient / carer advocate to ensure your views are respected Liaisons with other staff to ensure you receive care for your dementia as well as your physical needs Advice on developing a support plan to prevent hospital admission or a crisis emerging, developing our workforce by providing awareness and more in-depth training to our health care professionals and our support staff and promoting positive dementia care Help and support for patients and carers to make future plans Diabetes DESMOND The course covers: Thoughts and feelings of participants Understanding more about diabetes and blood glucose How being diagnosed with diabetes can affect long term health Healthy food choices The benefits of exercise Planning for the future