Out of hospital services
NHS Great Yarmouth and Waveney has set up some innovative out of hospital services in Lowestoft which we are now hoping to roll out across the whole of Great Yarmouth and Waveney.
The out of hospital team in Lowestoft works 24/7 and is made up of health and social care professionals whose aim is to provide care at home whenever it is safe, sensible and affordable to do so. The care the team is expected to provide will be organised around the patient, focusing on individual need and helping people to regain independence.
The team works closely with the patient’s own GP with an aim to provide care for patients in their own homes as far as possible. The team also has access to beds with care within a care home environment for patients who need more support than can be provided at home but who do not need to go into hospital.
When we were setting up the team we asked patients what they wanted and they told us that they want to stay at home when possible.
- Better patient experience helping patients to retain independence
- Recover faster and more fully
- Help patients to maintain dignity
- Reduced exposure to infections which can be picked up in hospital
The new team work out of the Kirkley Mill Health Campus in Lowestoft and is made up of:
- Occupational therapists
- Social workers
- Healthcare practitioners
- Health care assistants
Already we have had a number of successes with the team; we have seen the number of emergency admissions from the Lowestoft area fall whilst they have risen elsewhere in the county.
Mr A was found living in a very poor state, he had previously declined to go into hospital for care but was unable to care for himself, his pets or his home. Mr A had been in bed for five days and not called anyone for help, he was dehydrated, malnourished and not able to take any medication.
Within two hours of being made aware the Out of Hospital team visited with a nurse, an assessor from social services and a co-ordinator from home first (re-ablement staff).
The team arranged input from a community matron, a district nurse and an occupational therapist, a referral back to the GP for review of medication and a referral to the continence team.
Social care arranged for home first to start that day; a key safe and Suffolk Care Line were installed; the property was cleaned and a benefits check carried out.
If this patient had gone directly into hospital the opportunity to identify and address all the social needs as well as all the health needs would have been missed!
Mrs B was known to have dementia, frequent dizzy spells and she had had recurrent falls over a five day period. Her wider family were struggling to cope.
The out of hospital team were called and within one hour of referral a joint health and social care assessment had been made, including full blood tests.
The out of hospital team were able to make sure that Mrs B had equipment provided to help her remain independent at home, her husband was given help and taught how to help Mrs B with her exercises to keep her mobile.
Her GP reviewed her medications to make sure that they were still appropriate and Carers were put in place to support Mrs B and her husband. The wider family were reassured that it was safe for Mrs B to remain at home with the right support in place.
A referral was made to mental health services so that Mrs B and her husband could get support in living with her dementia.