Glasgow City CHP North East Sector

Transcription

1 Glasgow City CHP North East Sector Student Placement Programme May to September

2 Index Index Page 2 Introduction and Welcome from Practice Development Team Page 3 A Note from the Senior Management Team Page 4 Community Services Student Information Page 5-6 Flyer Page 7 Booking Form Page 8-11 Flowchart for Student Placements Page 12 Notes on Clinical Sessions Page Reflective Practice Page 15 Community Older Peoples Team Page Diabetes Page District Nursing Page Health Improvement and Inequalities Page 31 Health Visiting & Public Health Page 32 Intranet for Nurses Page 33 Nutrition and Dietetic Service Page 34 Podiatry Page 35 Oral Health Action Team Page 36 Palliative Resource Nurses Page 37 Parents and Children Together (PACT) Page School Nurses Page Treatment Room Page 46 Movement Disorder Service Page 47 Speech & Language Therapy Service Page Practice Education Facilitator (PEF) Page 50 Psychiatric Nurses (Anvil Centre) Page Breastfeeding Awareness Page 53 Primary Care Mental Health Team Page 54 Bus Routes Page

3 Introduction and Welcome Welcome to North East Sector of Glasgow City Community Health Partnership All staff are dedicated to ensuring you receive a wide variety of experience during your placement time here. To assist them this programme has been developed, with their involvement, to raise your awareness of the diversity of services and staff roles and responsibilities. The Programme has also been designed to assist students to meet the outcomes required for their placement. Quality practice placement experiences, within a positive learning environment, support the development of healthcare professionals to deliver safe and effective person centred care Quality Standards for Practice Placements NHS Education for Scotland 2 nd edition (2008) We hope the programme provided will be a valuable resource both during your placement and after. As such we ask for your constructive comments. We hope you enjoy your time within North East Glasgow Sector of Glasgow City CHP and the remainder of your training. If we can be of any assistance during your time here or afterwards please do not hesitate to contact us. Practice Development Team Marie Helen Marie McEwan Helen Pickering

4 WELCOME and BACKGROUND Welcome to Glasgow City CHP North East Sector. We would like to extend a warm welcome to you during your placement within the North East Sector. Glasgow City Community Health Partnership (CHP) came into being in November It is responsible for the provision of Primary Care and community services to the people of Glasgow, and for improving health and wellbeing. The new CHP covers the geographical area of Glasgow city council, a population of 584,000. The North East Sector is one of three sectors which make up the new CHP and covers a population of 178,000.The sector has approximately 1500 staff, and is responsible for a budget of over 150m per year. In addition the Sector manages budgets for Glasgow City Homelessness and Asylum Seeker Health Services and Specialist Children s services for NHS Greater Glasgow and Clyde. The Geographical area that North East sector covers is Springburn, Dennistoun, Bridgeton, Dalmarnock, Carntyne, Parkhead, Shettleston, Tollcross, Baillieston, Easterhouse, Garthamlock as well as covering the city centre area. Services are delivered from 7 large Health Centres; Bridgeton, Townhead, Parkhead, Shettleston, Baillieston, Easterhouse, Springburn, as well as a number of Clinics and GP Practices. The Sector manages the following NHS Services and functions: Community nursing, health visiting and school nursing; Relationships with primary care contractors; Local older people s and physical disability services; Chronic disease management programmes and staff; Allied health professionals; Community mental health services; Learning disability services; Homeless and asylum services; Health improvement and planning; Resource transfer arrangements with the city council; Specialist community children s services and child and adolescent mental health; The sector also manages Homelessness and asylum seeker health services for Glasgow City. Specialist children s services for Glasgow City CHP and NHSGGC (These include Community Child Health (CCH) and Child and Adolescent Mental Health Services (CAMHS) Local and specialist health and social care addiction services are managed through a formal partnership arrangement with the City Council. North East Sector is committed to improving services for all our patients and we hope your experience with us will clearly demonstrate this ethos. We have a very committed staff across all disciplines and we continue to work to make improvements in all our services to ensure the best possible care for our patients. We trust you will enjoy your experience within the North East Sector and wish you every success. Mark Lorna Paul Mark Feinmann Lorna Dunipace Paul Ryan Sector Director Head of Primary Care and Community Services Clinical Director 4

5 NHS Greater Glasgow & Clyde Glasgow City CHP North East Sector Student Information This Booklet contains information about the Community Services within NHSGG & Clyde. Information regarding your current placement will be given to you where available. About Community Services Switchboard Telephone No s Provision of learning opportunities Access to placement related visits Please bring along your portfolio to share with your mentor as this will allow discussion around your prior learning and experiences. Remember! Bring along your assessment documentation and learning outcomes early in your placement. Baillieston HC Bridgeton HC Easterhouse HC Parkhead HC Shettleston HC Springburn HC Townhead HC During your placement Whilst on placement in the clinical area you should expect: A named mentor (and in some areas a comentor) Initial discussion regarding your learning needs, outcomes and competencies Integration of theory and practice Regular feedback on your performance Supportive learning environment Increased clinical skills through participation in patient care activities 5 Your Mentor Mentors are experienced practitioners who have the necessary qualifications, education, training and experience in the assessment of students in the practice setting. They possess a wide range of theoretical and clinical skills appropriate to their clinical area. Your mentor will conduct a regular review of your learning needs, achievements and opportunities to enable successful achievement of your learning outcomes. Towards the end of your clinical placement, your mentor will conduct a fair and objective assessment of your performance.

6 Practice Education Facilitator Team Practice Education Facilitator roles have arisen from the need to ensure that NHS Education for Scotland s Quality Standards for Practice Placements are being met. The role of the Practice Education Facilitator is to: Facilitate links and develop educational opportunities between you, your mentor and HEI s Maximise the number of students who can be supported within clinical practice areas Ensure that the student experience is of the highest quality and enables the greatest benefit from the individual clinical learning experience Enhance and support the role of the mentor Establish and explore strategies to enhance the clinical learning environment Contribute to the selection, evaluation and audit of clinical practice placements. Smoking NORTH EAST CHP PEF ROSEMARY MIDDLETON Please note that NHSGGC operates a No Smoking Policy on all premises Car parking Car parking is extremely limited on all sites and may be subject to charges. Alternatively, public transport information is available at or telephone: Uniform Uniform may or may not be necessary during your community placement please discuss with your mentor, but dress must be comfortable, practical and appropriate. Please see local policy regarding dress/uniform code. Shift Patterns You may have the opportunity to experience weekend or evening shifts on your community placement. Sickness/absence Please inform: Your placement area The University Or (dependent on your programme of study) as soon as you know that you will be unfit for work. If possible give an indication of when you will be able to resume or let them know as soon as possible. Mobile Telephones The use of mobile phones is not permitted 6

7 Putting theory into practice Including: Child Protection Public Health E- Health Health Improvement Diabetes Palliative Care Older Persons Services Breast Feeding and more Running throughout your placement Full information available at: 7

8 BOOKING FORM STUDENT SESSIONS MAY TO SEPTEMBER 2012 STUDENT SESSIONS NAME COURSE & YEAR MENTOR BASE CONTACT NUMBER Name of Session Venue Date Time Select Session Homeless Team Bridgeton Health Centre confirmed (Office use only) Homeless Team Bridgeton Health Centre Homeless Team Bridgeton Health Centre Homeless Team Bridgeton Health Centre Parkinson s Disease Bridgeton Health Centre Parkinson s Disease Bridgeton Health Centre Parkinson s Disease Bridgeton Health Centre PRN, End of Life PRN, End of Life Eastbank Conference & Training Centre Eastbank Conference & Training Centre Signature of Student Date Signature of Mentor Date Completed forms should be returned to Carole Armour Shettleston Health Centre 420 Old Shettleston Rd Glasgow G32 7JZ Tel: Fax: Or James O Neil Bridgeton Health Centre 201 Abercromby St Glasgow G40 2DA Tel: Fax PLEASE NOTE THAT NO BOOKINGS WILL BE MADE UNLESS THE BOOKING FORM IS RETURNED SIGNED BY BOTH THE MENTOR AND THE STUDENT 8

9 BOOKING FORM STUDENT SESSIONS MAY TO SEPTEMBER 2012 STUDENT SESSIONS NAME COURSE & YEAR MENTOR BASE CONTACT NUMBER Name of Session Venue Date Time Select Session Health Improvement Eastbank Conference & Training Centre Health Improvement Eastbank Conference & Training Centre Health Improvement Eastbank Conference & Training Centre Health Improvement Eastbank Conference & Training Centre Breast Feeding Eastbank Conference & Awareness Training Centre Breast Feeding Eastbank Conference & Awareness Training Centre Breast Feeding Eastbank Conference & Awareness Training Centre Diabetes Team Bridgeton Health Centre confirmed (Office use only) Diabetes Team Bridgeton Health Centre Diabetes Team Bridgeton Health Centre Signature of Student Date Signature of Mentor Date Completed forms should be returned to Carole Armour Shettleston Health Centre 420 Old Shettleston Rd Glasgow G32 7JZ Tel: Fax: Or James O Neil Bridgeton Health Centre 201 Abercromby St Glasgow G40 2DA Tel: Fax PLEASE NOTE THAT NO BOOKINGS WILL BE MADE UNLESS THE BOOKING FORM IS RETURNED SIGNED BY BOTH THE MENTOR AND THE STUDENT 9

10 BOOKING FORM STUDENT SESSIONS MAY TO SEPTEMBER 2012 STUDENT SESSIONS NAME COURSE & YEAR MENTOR BASE CONTACT NUMBER Name of Session Venue Date Time Select Session District Nursing Shettleston Health Centre confirmed (Office use only) District Nursing Shettleston Health Centre District Nursing Shettleston Health Centre District Nursing Shettleston Health Centre Primary Care Springburn Health Centre Mental Health Primary Care Springburn Health Centre Mental Health Primary Care Springburn Health Centre Mental Health Practice Nursing Bridgeton Health Centre Practice Nursing Bridgeton Health Centre Practice Nursing Bridgeton Health Centre Signature of Student Date Signature of Mentor Date Completed forms should be returned to Carole Armour Shettleston Health Centre 420 Old Shettleston Rd Glasgow G32 7JZ Tel: Fax: Or James O Neil Bridgeton Health Centre 201 Abercromby St Glasgow G40 2DA Tel: Fax PLEASE NOTE THAT NO BOOKINGS WILL BE MADE UNLESS THE BOOKING FORM IS RETURNED SIGNED BY BOTH THE MENTOR AND THE STUDENT 10

11 BOOKING FORM STUDENT SESSIONS MAY TO SEPTEMBER 2012 STUDENT SESSIONS NAME COURSE & YEAR MENTOR BASE CONTACT NUMBER Name of Session Venue Date Time Select Session Awareness Raising Eastbank Conference & Domestic Violence training Centre Awareness Raising Eastbank Conference & Domestic Violence training Centre Awareness Raising Eastbank Conference & Domestic Violence training Centre Awareness Raising Eastbank Conference & Domestic Violence training Centre Hospice Visit - Marie Curie Hospice :00-16:00 Palliative Care Hospice Visit - Marie Curie Hospice :00-16:00 Palliative Care Hospice Visit - Marie Curie Hospice :00-16:00 Palliative Care Hospice Visit - Marie Curie Hospice :00-16:00 Palliative Care Palliative Care - Shettleston Health :00-16:00 District Nursing Palliative Care - District Nursing Centre Shettleston Health Centre :00-16:00 confirmed (Office use only) Signature of Student Date Signature of Mentor Date Completed forms should be returned to Carole Armour Shettleston Health Centre 420 Old Shettleston Rd Glasgow G32 7JZ Tel: Fax: Or James O Neil Bridgeton Health Centre 201 Abercromby St Glasgow G40 2DA Tel: Fax PLEASE NOTE THAT NO BOOKINGS WILL BE MADE UNLESS THE BOOKING FORM IS RETURNED SIGNED BY BOTH THE MENTOR AND THE STUDENT 11

12 BOOKING FORM STUDENT SESSIONS MAY TO SEPTEMBER 2012 STUDENT SESSIONS NAME COURSE & YEAR MENTOR BASE CONTACT NUMBER Name of Session Venue Date Time Select Session confirmed (Office use only) NE Rehabillitaion Team NE Rehabillitaion Team NE Rehabillitaion Team NE Rehabillitaion Team Shettleston Health Centre Shettleston Health Centre Shettleston Health Centre Shettleston Health Centre Speech & Language Bridgeton Health Centre Speech & Language Bridgeton Health Centre Speech & Language Bridgeton Health Centre Signature of Student Date Signature of Mentor Date Completed forms should be returned to Carole Armour Shettleston Health Centre 420 Old Shettleston Rd Glasgow G32 7JZ Tel: Fax: Or James O Neil Bridgeton Health Centre 201 Abercromby St Glasgow G40 2DA Tel: Fax PLEASE NOTE THAT NO BOOKINGS WILL BE MADE UNLESS THE BOOKING FORM IS RETURNED SIGNED BY BOTH THE MENTOR AND THE STUDENT 12

13 Glasgow City CHP North East Sector Flowchart for Student Placements Student receives copy of flyer and step by step guide to access programme. Student Accesses Programme Mentor and student discuss content and student selects sessions they wish to attend Student completes Student Placement Clinical Sessions booking form selecting appropriate sessions they wish to attend. Form to be sent or faxed to Carole Armour Shettleston Health Centre or James O Neill Bridgeton Health Centre. Confirmation of place will be sent to student/mentor. If late booking no confirmation will be sent verbal confirmation given If place booked but unable to attend please phone Carole Armour ( ) or James O Neil ( ) and advise mentor. Student to complete evaluation of each session attended. This is for governance purposes. 13

14 STUDENT PLACEMENT CLINICAL SESSIONS NOTES 1. An evaluation of each session will be undertaken. 2. Students are asked to write a reflective practice statement after the session and identify further learning needs and take responsibility in actively pursuing them. May the staff of the North East Sector wish you well and hope you have an informative and enjoyable time with us 14

15 EVALUATION OF CLINICAL SESSIONS Title of Session: Date of Session: Student Year in Training : Poor Excellent Overall value of clinical session as a learning experience Your awareness in the topic before the clinical session Your awareness in the topic after the clinical session Opportunity to contribute Opportunity to ask questions Will what you have learned change what you do? YES NO Why do you say this: Do you have further information needs in relation to this topic? Please specify. Would you like further information on this topic? Please specify. Thank you for taking the time to complete this evaluation Please return completed form to Carole Armour, Admin Assistant, Shettleston Health Centre, 420 Old Shettleston Road, Glasgow G32 7JZ Or James O Neil Bridgeton Health Centre 201 Abercromby St Glasgow G40 2DA Tel: Fax

16 Glasgow City CHP North East Sector Reflective Practice Name: Date of Clinical Session: Topic of Clinical Session: What were my personal objectives for this study day? Were they met? What important points have I taken away from today? What changes, if any, will I make to my practice? What is my action plan to achieve these changes? The forces I see helping me are: I will assess my success by: 16

17 Glasgow City Community Health Partnership North East Sector Rehabilitation Service APRIL

18 Background In May 2011 three services merged. They were previously known as the Community Older Peoples Team (COPT), the Interdisciplinary Response and Intervention Service (IRIS) and the Community Physical Disability Team and became The Glasgow City CHP Rehabilitation Service who will deliver local community rehabilitation services. The re - designed services will provide a range of services to meet the health and care needs of all older people and adults with a physical disability within a local structure. The model of service delivery will encourage patients to be as independent as possible by focussing on self-care and self-management. Definition The Glasgow City CHP service specification reflects the strategic Framework for Adult Rehabilitation in Scotland and engagement with a range of other stakeholders. A process aiming to restore personal autonomy to those aspects of daily life considered most relevant by patients or service users, and their family carers. Rehabilitation Services Within North East Sector there are two bases and access to Acute Sector facilities for hospital discharge. The two bases in the North East Sector will be Stobhill Hospital and Parkview Resource Centre and will serve a defined geographic patch. Team Members Dietetics General and Psychiatric Nursing Occupational Therapy Physiotherapy Speech and Language therapy (under 65s) Clinical Psychology ( under 65s) Clinical Pharmacy Podiatry Consultant Geriatrician sessions Rehabilitation Assistant Administration 18

19 Service Provision Acute Hospital Liaison Rapid Response A&E (Ihr) GP (4 hrs) Interdisciplinary Rehabilitation Intervention in the home Care Co-ordination Consultant Review In addition to the availability of a wide range of specialist therapies within the Team, the unique combination of sharing skills focussed on individual need enables all staff to be more effective in their treatment. Symptom Management prevention of secondary complications to minimise the impact of further deterioration. This can result in increased comfort for patients and positive advice to carers and relatives. It can also facilitate self-management of condition. Rehabilitation goal focussed input to enhance health status, increase levels of activity, improve level of function and enable access to opportunities for increased participation. Education and training - Intervention is targeted to achieving present patient centred goals within an agreed timeframe. Affecting early supported discharge and prevent admission to hospital In a systematic way, address the learning and practice needs of other Health Professions Referrals Referrals to the service are received to a Single Point of Access. (SPOA) North East Sector SPOA Tel No: (Internal 13210) The service is closed only on Christmas and New Years Day. Referrals are received from Health, Social Work professionals and also other agencies ie Cordia, voluntary sector, housing and appropriate self referral will be accepted. 19

20 Criteria for Service Provision Inclusion Criteria The patient will be aged 16 years and above The patient lives in Glasgow City or admitted to a Glasgow Hospital facility for community intervention The patient is registered with a General Practitioner The patient is medically fit for discharge The patient can consent to involvement in treatment The patient can benefit from early supported discharge having ongoing nursing and rehabilitative needs, which can be met at home as an alternative to remaining in hospital The patient can be included as an alternative to hospital admission when no need identified for inpatient intervention The patient is at risk of deterioration in function if immediate ongoing rehabilitation is not provided The patient has had an acute episode of iilness/injury which requires rapid access to equipment or homecare, that is otherwise unavailable to support them returning/staying at home A&E admission avoidance for patients residing in the North East and North West Sectors Exclusion Criteria The patient is under 16 years of age The patient lives in a geographical area with no rehabilitation team provision on discharge from hospital The patient is not registered with a General Practitioner. It the patient is not registered with a GP, the team will give support to assist the patient to access one The patient is not medically fit for discharge The patient cannot consent as a result of cognitive impairment The patient has long-term complex needs is already receiving maximum care package or is actively managed by another service due to a primary condition e.g. spinal injury and brain injury The patient s needs cannot be met with a short-term intensive package of care/therapy. The patient s level of cognitive impairment prevents safe discharge/remaining at home The patient requires hospital admission or is unsafe for discharge home Patients residing in the South Sector 20

21 The Team who visit you are based at Stobhill Office Parkview Office If there is no-one available, please leave your name and telephone number on the voice mail, and we will return your call North East Sector Rehabilitation Service If you have either any comments or complaints about the Service, please contact the Team Leader on the above number. Appointments / Diary / Comments Mon Fri 8.30am to 4.30pm An information leaflet for patients, carers and relatives 21

22 Rehabilitation aims to improve your independence and quality of life at home. Community Nurse Podiatrist Dietitian The service will support you: o To manage your condition o To improve your health o To return to your daily routine (e.g. leisure activities,work,lunchclub) o To support your discharge from hospital o To live independently at home or at a place of your choice o To return to work Occupational Therapist Pharmacist Physiotherapist Psychologist Community Psychiatric Nurse Rehabilitation Support Worker Speech and Language Therapist The first visit will be an assessment from our service to help us find out more about your individual needs. We will help you to set goals for the activities which are important to you. This may include links to other services. The Rehabilitation Service consists of: You may be visited by one or more of the team members for a period of time If at any time you feel unwell, please contact your own GP as normal 22

23 Community Diabetes Specialist Nurses Background The role of the Diabetes Specialist Nurse in the community was developed with the introduction of the Glasgow Diabetes Project. This was aimed at providing a new integrated service involving both NHSGGC Primary and Secondary Care. Nursing team members consist of; 2 Diabetes Specialist Nurses 1 Staff Nurse Aims and Objectives of Service To provide a highly specialised diabetes management, treatment and education service to patients referred from both Primary and Secondary Care Act as a resource for expert advice and training for nursing staff, medical staff and other healthcare professionals and other agencies Lead and contribute to issues relating to diabetes care locally and nationally where appropriate Carry out audit and research work in connection with all aspects of diabetes care. Criteria for Service Provision Patients living with type 2 diabetes attending Primary Care Patients living with type 1 diabetes, who have defaulted from secondary care, with the ultimate aim for them to re-attend secondary care To standardise diabetes care across Glasgow Develop and deliver education for staff, patients and carers To develop policies, protocols and guidelines in line with SIGN and Scottish Diabetes Framework Exclusions Patients living with type 1 or type 2 diabetes who are pregnant, or considering pregnancy Children and adolescents living with diabetes Patients presenting with symptoms of type 1 diabetes Patients presenting with alternative genetic types of diabetes e.g.: mody 23

24 Functions Manage a caseload of patients with multiple complex problems, co-morbidities complicated by psychosocial issues, by delivering complete programmes of care in relation to their diabetes. Receive and act upon clinical referrals directly from other healthcare professionals within both Primary and Secondary care settings and provide clinical expert advice to the multidisciplinary team, clinicians, patients and carers. Plan, implement and evaluate care and treatment given, including performing complete and comprehensive clinical assessments encompassing holistic practice, patient centred decision making and risk management. Care will be evidence based and appropriate to needs, context and culture. Work with multi-disciplinary team to develop and evaluate diabetes educational initiatives for large groups of healthcare staff e.g. GPs, PNs, DNs, Students), in addition to voluntary groups and AHPS, and monitor their impact on the care of diabetic patients Act as a professional resource to these groups. Co-ordinate and lead on the development of nursing guidelines and standards appropriate to diabetes within NHS Greater Glasgow & Clyde. Review and update these guidelines which influence clinical practice locally and/or nationally. Collaborate with other disciplines/professions in the participation of audit to ensure effective delivery of service. Contribute to and where appropriate lead on the development of board wide specialist diabetes education and training initiatives to staff as part of the NHS Greater Glasgow & Clyde Diabetes MCN Care pathway The community diabetes team receives referrals from GPs, Practice Nurses, District Nurses, Secondary Care and any other Health Care Professionals. To facilitate the referral process, the appropriate referral form is required to be completed (see attached). The Community Diabetes Specialist Nurse will assess and prioritise referrals in order to recommend appropriate clinical intervention, initiate treatment and provide ongoing care management in conjunction with education and health promotion. Once the agreed outcome of care has been achieved the CDSN refers the client back to GP and /or Secondary Care for continuing care. (see attached flow chart). 24

25 PRIMARY CARE Referral Pathway SECONDARY CARE Primary care written referral to cdsn for commencement of insulin Reviewed at Diabetes Centre requires insulin therapy Dietetic review DSN review patient able to attend Diabetes Centre to commence insulin Not for insulin treatment at this time Suitable for insulin treatment in primary care No Yes Discuss with link Consultant & GP Continue GP care Commence insulin as per Initiation Guidelines Follow up in secondary Diabetic clinic 25

26 REFERRAL TO COMMUNITY DIABETES SPECIALIST NURSE Angela McLaren, Diabetes Specialist Nurse & Marie Robertson, Diabetes Specialist Nurse Bridgeton Health Centre, 201 Abercromby Street, Glasgow, G40 2DA /1663 PATIENTS NAME MEDICAL INFORMATION Type 1 Type 2 Blood Sugar Height DATE OF REFERRAL Chol Creatinine CHI NUMBER REFERRED BY HbA1c ADDRESS IFCC (HbA1c) HOUSEBOUND Insulin YES NO YES NO RISK TO LONE WORKER Weight SIGNATURE LDL Urea GP BP Trig DATE DIABETES DIAGNOSED MEDICATION DOSE DIABETES GP PRACTICE MEDICATION CODE INSULIN DOSE METFORMIN YES NO ATTENDS SECONDARY CARE YES NO CONSULTANT REASON SULPHONYUREA FOR REFERRAL YES NO Monitoring Blood Urine Smoking YES NO Alcohol YES NO BMI HDL egfr GLITAZONE YES NO GLIPTIN YES NO INCRETIN MIMETIC YES NO MEDICAL HISTORY / OTHER RELEVANT INFORMATION CONCURRENT MEDICATION DOSE CONCURRENT MEDICATION DOSE 26

27 DISTRICT NURSING Background District nurses are nurses who have undertaken further training in meeting the health needs of individuals and carers within the community. District nurse teams are attached to the General Practitioner practices and form part of the Primary Health Care team Aims of Service To provide a 24 hour accessible, high quality, culturally sensitive and effective nursing service to all age groups in the community, by working in partnership with service users, care providers and other agencies. Objectives of Service To promote and maintain independent living through care management, skilled clinical interventions, health education and health promotion within the home setting and the wider community setting. Criteria for Service Provision Patients who are housebound or have a nursing need which makes a home visit more appropriate. Exclusions Patients who are ambulant and have no identified nursing need. 27

28 Functions The District nursing service will Use a holistic approach to assess, identify and prioritise health needs within the home setting and wider community setting Provide planned nursing care Adopt a clinically effective approach to all areas of practice. Administer medication and treatment and prescribe where appropriate. Manage nurse led clinics and provide specialist advice, diagnosis and treatment of many conditions. Promote user involvement in both service delivery and planning. Promote a co-ordinated approach to hospital discharge that ensures a seamless service leading to improved health outcomes. Provide health education, information and support for patients and carers. Adopts a public health approach and is actively involved in partnership working within the community in order to achieve local and national health targets. Participates in the education and training of student nurses and other Health and Social Care providers. Care Pathway The District nursing service operates an open access approach; it receives referrals from many agencies including social work, hospital, and hospice and from the public. To facilitate the referral process specific information on the District Nurse referral form (copy attached) is required. The District nurse will assess and prioritise referrals in order to provide nursing interventions and care management. Once the agreed outcomes for care are achieved planned discharge is facilitated with referral to other agencies if appropriate. DISTRICT NURSE REFERRAL FORM 28

29 Date : Referrer s name : Source : SW / DN/ GP / Hosp Ward/ Treat Rm./ Patient / PN/Other : Time : Tel no : Patient Name : CHI No : DOB : Home Address : (incl. flat no) Postcode Discharge Address (if different to above) Postcode Tel No : Mobile No : Access/Risk Issues/Special Needs Next of Kin/Carer : Relationship : Contact No : Mobile No : GP Name : Tel No : Address : Reason for Referral Is patient aware of referral to DN Service? Yes/No Previously known to DN services? Yes/No Diagnosis : Is patient aware of diagnosis Yes/No Date of visit as requested by referrer : Date of 1 st contact/visit : Relevant Medication Aid filled Yes/ No / Not Relevant Medication Supply given Yes / No 29

30 Dressings Supply Yes / No given Continence Aids Supply given Yes / No Wound Care Chart : Yes / No Equipment ordered (Please list): Type: Date: By whom: Designation: Other services involved or referred to (please list and as appropriate) SERVICE Currently involved REF TO DATE BY WHOM SSA Commenced : Yes / NO Date : By whom : Designation : This section to be completed by Community Nurses Only Inappropriate Referral? - YES / NO If YES Reason & Action Referral Form Completed by :. Signature :. 30

31 HEALTH IMPROVEMENT TEAM BACKGROUND The Health Improvement Team has a varied remit but centres on facilitating and/or managing projects designed to improve and protect the health of the local population, taking into consideration health inequalities and deprivation as well as community profiles. Health Improvement Staff come from a variety of professional backgrounds, including nursing, social sciences and education. Each Sector or CH(C)P within Greater Glasgow and Clyde has a Health Improvement Team who are based locally. Work is directed by National priorities, NHS GG&C priorities and local need. AIMS OF SERVICE The Health Improvement Team are involved (either directly or indirectly) in several services, including smoking cessation groups, cancer support groups, alcohol training & counselling as well as wider prevention and education projects. Health Improvement teams facilitate training for NHS colleagues and partner agencies and are often involved in community events to promote positive health messages. The prevention of ill health is arguably the focus of Health Improvement, so programmes around prevention and education, early intervention and health protection are priorities for the HI Team. OBJECTIVES OF SERVICE To improve and protect the health of the population of Greater Glasgow & Clyde by providing education programmes holistic health projects and engaging with communities. To support government imperatives, such as HEAT Targets (Health Efficiency Access Treatment). CRITERIA FOR SERVICE PROVISION Resident in the sector. EXCLUSIONS If a patient/service user is not resident within our boundaries we will refer to their local service. FUNCTIONS The Health Improvement Team cover various topics, within North East are divided into subteams of Early Years & Oral Health, Youth Health, Addictions, Older People, Cancer and Long Term Conditions, Mental Health & Arts, Physical Activity & Nutrition. Health Improvement staff are involved in a variety of projects and work collaboratively with partner agencies. The HI Team also support volunteering programmes for service users as part of condition maintenance or recovery. CARE PATHWAY FLOW CHART Various depending on project. From GPs, Social Work, Self referrals. PROCESS OF SERVICE PROVISION FLOW CHART n/a 31

32 HEALTH VISITING/PUBLIC HEALTH NURSING Background The Health Visitor/Public Health Nurse is a first level registered nurse who is required to complete post registration training in Health Visiting/Public Health Nursing. The Health Visitor/Public Health Nurse is an independent autonomous practitioner registered on the specialist part of the Nursing & Midwifery Council (NMC) Professional register. Health Visitors work within Children and Family teams, providing care for the 0-5 age group. Within these age groups, the Health Visitor identifies those individuals or families who require core support, those who require additional support and those vulnerable clients who require support that is more intensive. The Children & Families Teams may include: Specialist Public Health Nurse (Health Visitor) Staff Nurse Member of the Oral Health Action Team (OHAT) Nursery Nurse. Health Visitors are also involved in working within communities. Supporting and advising communities to identify their health needs by assessment, planned input, implementation and ongoing review Due to the nature of the Health Visitors role they have close working relationship with Social Work Department and when required joint assessments are carried out and sent to the Reporter to the Children s Panel when a child is deemed at risk Aims of Service To provide a universally accessible service through which to deliver Public Health focused work with individuals, groups and communities. Objectives of Service To make a holistic and systemic assessment of Children & Families needs safeguarding children and determining levels of intervention required. To provide support and advice on health and health issues to individuals and communities. To caseload-manage the Children & Families in their care. To identify and raise the awareness of vulnerable individuals and families of their health needs, supporting those communities or individuals in any life changes, which would improve their physical, intellectual, emotional social well-being.. Criteria for Service Provision Individuals registered with a General practitioner Individuals living/visiting in the community Self refer if need seen by client Function 1] Work with age group 0-5 in the area of primary, secondary and tertiary prevention. 2] Work with Communities where general populations will receive support in identifying health needs through assessment, planning, implementing and supporting any life changes that may be required by individuals /communities 32

33 INTRANET FOR NURSES Background PCD intranet site was developed to help improve internal communications by enabling staff to share information and news with colleagues across the organisation. It has now developed as a central portal which provides access to a number of information systems like community nursing, venue search, waiting times etc. It provides a one stop resource of all the services and information tools available to staff Aims of Service Better internal and inter organisational communication One-Point information access centre Empowering the Employees Cut down the time employees spend on routine communication tasks Reducing Information overload Increase Productivity Support decision making Objectives of Service Better informed employees by providing access to information from all sources, the Intranet could help our staff become aware of all events occurring in our highly structured organization. Better collaboration through group-scheduling and sharing information. We expect our staff to break the geographical and departmental barriers and become active members of a virtual community. New technologies could play here the role of enablers. Seamless cross-platform application access Efficient transfer of information Criteria for Service Provision Staff member and access to a computer or Winterm connected to the PCD Network Exclusions N/A Functions Information on primary care division categorised into Department sites, Info centre, Conf & Events, Media News, Expenses and Applications Flow Chart Intranet Author Intranet Authoriser Info. Published 33

34 NUTRITION AND DIETETIC SERVICE Background The role of the Dietetic Service in the North East Sector is wide ranging and aims to contribute to an overall service on nutrition issues for the general public. The work of the Dieticians comprises three broad functions: Clinical treatment Health promotion activity Support and training to others. Aims of Service To provide a high quality Dietetic Service which is tailored to meet the nutritional needs Of the local population. This will be achieved by:- Provision of expert dietary advice to patients, carers, advocates and agencies. Provision of health promotion advice aimed at preventing disease. Objectives of Service These will be achieved by:- Providing expert dietary advice to patients, carers, advocates and agencies. Providing health promotion advice aimed at preventing disease. Criteria for Service Provision Referrals to the service for clinical treatment come via a member of the Health Care Team, referral pathways and treatment guidelines are in place for people with specific clinical conditions. Health Promotion activity is planned annually in conjunction with CHP s, Health Promotion colleagues and relevant partners, targeting priority groups and topics. Training and support is offered to a range of staff groups and other agencies. The service also provides placements for Dietetic Students. 34

35 Podiatry Service BACKGROUND Podiatrists have completed a 4 year BSc degree in Podiatric Medicine and are all HPC Registered. We are part of the AHP structure and the Primary Health care team providing routine care in the clinical setting and also within patient s home if they are completely housebound, as well as Nursing and Residential homes. The service also provide specialist services in Nail Surgery, Biomechanics, foot health education, acupuncture and Diabetic assessment within GP surgeries. AIMS OF SERVICE Podiatry Service aims to provide a high quality, culturally sensitive and effective service to all age groups. We provide this service to anyone who requires Podiatry input due to a foot problem they cannot self manage or have a medical problem who would otherwise place their foot at risk. OBJECTIVES OF SERVICE Podiatry focuses on supporting patients to remain independently mobile and pain free while promoting self care wherever possible. Our aim is to provide podiatry care and foot health education to those who need it most, by a team of skilled professionals who are constantly learning and developing. CRITERIA FOR SERVICE PROVISION Patients can self refer to our clinical service for assessment of their clinical need via the central call centre or if housebound, will require a GP referral. EXCLUSIONS No exclusions to the service however patient will be discharged if they can self manage or have no Podiatric need. Similarly is patient is not housebound they will be discharged to the clinical setting. FUNCTIONS Patient centred care Promotion of self-care and enablement Sensitive to all patients in relation to equality and diversity Equity of care Accessibility, Flexibility and Sustainability Evidence based best practice Partnership working Skilled staff providing high quality services Involving all staff in decision making Accountable to NHSGG&C and our patients CARE PATHWAY FLOW CHART Podiatry Service operates an open access approach and receives referrals from many agencies. The Podiatrist will assess all patients referred and a detailed treatment plan will be agreed with each patient and a planned discharge facilitated if this is indicated. 35

36 Background In 2002, the Scottish Executive set a target for 60% of P1 schoolchildren to have no obvious dental decay experience in their deciduous teeth by On completion of the National Dental Inspection Programme 2009/2010, the results show that 64% of P1 children in Scotland were found to be decay free, compared to 58% in the P1 survey of Overall, the results for the 2009/2010 have exceeded the national target of 60% with no obvious decay experience, set for this age group by the Scottish Government. However, the oral health of Glasgow s children is still poor, even though the latest figures are showing great improvements in their oral health for many years: Across NHS Greater Glasgow and Clyde: - the proportion of 5 yr olds with no obvious decay experience has increased from 34% in 1999/00 to 42% in 2003/04, and more recently in 2009/10, 58%, however, that still means that 42% of our 5 year olds have decay! - There has been a decrease in average number of decayed, missing or filled teeth from 3.5 to Oral Health Action Teams (OHATs) work within Health Improvement Teams and operate across Greater Glasgow & Clyde. Each OHAT takes a multidisciplinary approach to improving oral health through the development of appropriate locally based initiatives. The approach adopted by the team is based on community development principles, which actively seek public involvement in all activities. Vision of the Team The development of a generation of children in Greater Glasgow who grow up actively engaging in oral health promoting behaviour, benefiting from good oral health and accessing dental services with appropriate regularity. Objectives of the Service To carry out local needs assessment and area profiling, and to develop and implement a yearly local action plan to address local priorities and identify gaps in the service. The key themes for implementation are: Smile Too Nursery Programme Childsmile Programme Oral Health Training Community Involvement Targeting 0 3 year olds Target Group The remit of the team is primarily to improve the oral health of pre-5s. In order to do this the OHAT must work with a whole range of groups and individuals who have contact with this age group and their parents/carers. This includes staff within the NHS as well as from Glasgow City Council and local voluntary agencies, and, most importantly, from the local community itself, e.g. nurseries, health visitors, dentists, parents/carers, toddler groups etc. This target group may change or widen in the future. 36

37 North East Sector PALLIATIVE RESOURCES NURSE NETWORK PALLIATIVE RESOURCE NURSES Background Palliative Resource Nurse Network established approximately 5 years ago due to increased interest and request for knowledge on palliative care. Aims of Service To cascade information to colleagues in Primary Care Team, students visiting and patients and relatives. Objectives of Service 1. Provide updates on palliative care. 2. Network with colleagues in Primary Care Team. 3. Involve colleagues in audits. 4. Education in palliative issues to colleagues. Criteria for Service Provision Practice Resource Nurse must be: Registered General Nurse working in community with an interest in palliative care. Able to avail themselves to meetings. Exclusions Functions Palliative Resource Nurses: 1. Provide information to colleagues. 2. Update colleagues on new developments. 3. Be involved in teaching new skills or updating practice. 37

38 PARENTS AND CHILDREN TOGETHER (PACT) What is PACT? PACT stands for Parents and Children Together. We are a multi-agency team consisting of staff from the health service, voluntary sector and social work. We are also supported by education services. Who we are The team includes community nursery nurses, health support workers, health visitors, social care workers and social workers. We also have links with money advice and speech therapy. Students from health and social work services may also be part of the teams. Our Aim We aim to help improve the health and wellbeing of your and your family. Our team can support you and your family for an agreed period of time, depending on what you need. Your involvement in this is important to us and we will work in partnership with you and other services involved in your care, e.g. health visitor, nursery, social services, GP. Services we can offer The team can work with you and your family in many ways. This may be on a one to one basis or in small groups. We can also assist you to make contact with other groups in your local area. Some of the ways we can work with your and your family include: Reducing isolation Confidence building and self esteem Positive parenting Play and development Debt advice Healthy lifestyle Support and assistance during times of stress Childcare advice and support Advocacy Support to access other services This list is just an example of some of the services our team can offer. The services you receive will be designed to meet the needs of you and your family. 38

39 PACT Referrals Parents and Children Together Information on Referrers Parents and Children Together (PACT) is a multi-agency team comprising staff from Health, Social Work and the voluntary sector, with support from Education services. PACT teams aim to demonstrate that child and family well-being for vulnerable and disadvantaged families can be improved through an integrated and cohesive multiagency approach to the provision of care. Through a referral system the teams provide intensive, time-limited, planned interventions and support for vulnerable children and families. The principle of the service is that it will focus on early intervention work with families on a voluntary basis, where this input is expected to limit or reduce the need for more intrusive and/or statutory measures. Where there is an immediate concern for the care or protection of child/children, referral should be made to the appropriate Area Social Services Department following Glasgow Interagency Child Protection Procedures. The multi-agency nature of the Team should be made clear to families before obtaining their consent to referral, as part of the working agreement with the families will explicitly require the Team to have consent to the sharing of information between agencies. It will be the responsibility of the Team to obtain this consent in writing: however the referrer should inform the family of this prior to making any referral. There are two PACT teams in each Community Health and Care Partnership (CHCP) area, each covering the same boundary as the current Area Social Services Department. In the East Glasgow CHCP the team bases are as follows: NORTH EAST PARENTS AND CHILDREN TOGETHER SOCIAL WORK SERVICES CAIRNBROOK CENTRE 101 CAIRNBROOK RD EASTERHOUSE GLASGOW G34 0NB PHONE EAST PARENTS AND CHILDREN TOGETHER FLATS 0/1 & 0/2 49 LILY STREET DALMARNOCK GLASGOW G40 3HD PHONE FAX

40 Referral Process Telephone enquires to the Team Leader to discuss potential referrals are welcomed. Copies of the Referral Form are available electronically and from the Administration Assistants at the team bases. Written referral forms should be completed in full and returned to the Team Leader at the appropriate base. At present, due to data protection issues, electronic Referral Forms should be completed, printed and then posted to the Team not returned electronically. Posting of person identifiable health information should follow agreed Agency Policy. It is anticipated that prior to referral, the referrer will, with the family consent, have liaised with the universal services involved with the child/family in order to establish other current supports and services being provided and discuss potential referral to Team. As all pre-school children have named health visitor, any children and families referred to the Team will be notified to this health visitor. Care Pathway PACT offers a range of potential interventions, designed on an individual basis to meet specific family need. The Team approach is one of openness and honesty with families, and of partnership working with families, referrers and other services involved in supporting the family. The Team aims to work in such a way as to enhance the inherent strengths of children and their parents, and promote positive change. This multi-disciplinary approach allows for a range of potential interventions to meet a variety of child and parental needs. For example: Individual Work with parents and with children. This might include increasing selfesteem, reducing isolation, addressing emotional needs, increasing individuals resilience, promoting play and development, fostering development of positive relationships and addressing individual health and lifestyle choice issues. Parenting Work individually and/or in groups. This would include looking at needs of a child, child development, managing behaviour, parenting experience, parentchild interaction and bonding. Practical Support This might include debt and benefits work, household routines, shopping, childcare support, advocacy with housing issues, attending to child health needs, putting parenting into practice, accessing other services and supports i.e. literacy worker, training and/or employment. Group Work A range of group work options will be made available to parents, to children and for families together. These will vary according to needs of families working with the Team at any particular time, but are likely to include Women specific and Men specific groups, focusing on building confidence, self-esteem, social skills, play and development needs and reducing isolation. 40