Referral to intermediate care nursing

 

This is a joint initiative between Barnsley Primary Care Trust and BMBC  Adult Social Services to provide a range of services offering multi-disciplinary rehabilitation, treatment and support to residents of the Barnsley Borough to enable people to receive care and treatment in their own homes, or as near to their own home as possible, for a short period of time, as an alternative to being in the acute hospital by:

• Providing skilled nursing care, therapy and social support in the patientÂs own home (Rapid Response and Hospital at Home Teams).
• Providing skilled nursing care and therapy for a short period of time to compliment the care in social service Locality centre bed.
• Providing skilled nursing care, medical care and therapy in Mount Vernon Hospital for those people who need 24 hour assessment and treatment
• Facilitating the transfer of patients to a nursing home bed where appropriate, for a fixed period, with support from the rapid response team.
• Providing additional nursing and/or social support to enable people to remain in their existing residential/nursing home bed.

 

You may benefit from the service if you are:

• A patient suitable for intermediate care following assessment,
• A patient who agrees and is able to participate in the care plan.
• A patient who is registered with a Barnsley GP or who lives in the Barnsley Borough
• Carers (where applicable) are in agreement with the care plan.
• The GP continues to accept medical responsibility for the patient (for other than Mount Vernon Hospital).
• Usually an older person although younger people may benefit from the services

 

Procedure

 

Medically stable

Referrals are made to the Intermediate Care Assessment Team for patients in hospital wards, medical assessment unit, accident and emergency department and from community for people who are medically stable but needing recuperation, rehabilitation or further assessment via the health or social care staff involved in the care of the patient (e.g. ward staff, community nurse, care manager). The team can access beds in any of the intermediate care facilities, according to the patientÂs needs.

Admission avoidance

Referrals cannot be accepted from patients/ carers direct
Your GP can contact the ÂRapid Response Nurse direct via the mobile telephone number, as she/he will most likely be out in the community visiting patients. If the doctor feels that your condition could be treated at home. An assessment will be carried out by the Rapid Response Nurse to determine the amount and type of care needed. The assessment can be carried out anywhere whether it is at home in hospital or in residential care. Following an assessment: As an example, we can provide support for the following types of illness/conditions:

• Exacerbation of chronic conditions e.g. chronic obstructive pulmonary disease (COPD) and asthma.
• Short term acute care e.g. cellulitis, DVT (blood clots), chest infection
• Reinsertion of PEGS (in emergency only).
• Terminal care
• Mild stroke/Transient Ischemia
• Dehydration
• Following a fall.

We can provide the following types of care:

• Acute nursing care
• Occupational Therapy, physiotherapy, speech and language therapy or input from dieticians
• Social care as part of a package
• Nebulisation and O2 therapy
• Neurological observations
• Administration of medicines
• Phlebotomy / obtaining specimens as part of care package
• Pain assessment
• Support and training for staff in Nursing homes and Resource centres.
• Out of hours District Nursing cover 5.30pm - 8.30am

 

 

Helplines

 

RAPID RESPONSE
07747 794698 (referral to Rapid Response by GP or nominated representative / A& E dept/ Social Services Emergency Duty Team)

PATIENTS MUST TELEPHONE BDGH SWITCHBOARD AND ASK FOR RAPID RESPONSE NURSE (this a health and safety issue if unknown callers contact the nurse direct)

INTERMEDIATE CARE
Intermediate Care Assessment Team 9.00am  9.30pm
Tel 01226 777097 or 01226 730000 Bleep 419 or 638

Other general service enquiries to Betty Franklin Intermediate Care Co-ordinator Tel 01226 433206.

 

Opening Times

This service is available 24 hours a day, 7 days a week, focusing on intermediate care needs in the community.

How the customer can help

 

The customer can be Social Services, Service User/Carer, GP, District Nurses, Hospital Wards/Accident & Emergency; it helps the Rapid Response Nurse or the Intermediate Health Professional if the customer can provide concise information about the emergency via a contact assessment form.

 

 

Response Times and Next Steps

 

• An initial assessment will be made within 2 hours of referral
• A full nursing and social care plan including anticipated discharge arrangements for on-going care will be made within 24 hours.
• The GP will be informed within 24 hours of the package of care and will be kept informed of the patient's progress on at least a daily basis (or as agreed with the GP).