A new pilot service is helping unwell older people in Wisbech and Ely get the urgent support they need to be cared for at home, when they need it.
Cambridgeshire Community Services NHS Trust has launched a year long community rapid response scheme for patients registered with GP practices in the Ely area and Wisbech.
GPs, paramedics and other medical professionals can contact a senior nurse who will arrange for the most appropriate professional from the multi-disciplinary service to visit their patient at home. They will then assess them to determine the type of care and support they need to recover – either at home or a short stay in a community hospital.
The multi-disciplinary service includes nurses, occupational therapists, physiotherapists social care managers, a consultant geriatrician, pharmacists, multi-skilled healthcare assistants and others.
Ross Collett, Local Chief Officer for Wisbech and Isle of Ely Local Commissioning Group (LCG), said: “The service aims to ensure that people who are in a crisis situation, but do not need to go to hospital, receive the best care possible in the most appropriate place. Most people in this situation are better cared for in their own homes, but need a lot of support from medical and social care staff for this to happen. As commissioners of NHS services, it is good to see so many NHS providers working in partnership to support patient’s needs.”
Mike Passfield, Head of Nursing (Unplanned Care, Ely & the Fens Community Unit) Cambridgeshire Community Services NHS Trust, said: “We have designed the service to complement existing community services run by the Trust such as district nursing, intermediate care, re-ablement, therapies and in-patient wards in community hospitals, and will be working closely with these services.”
The service provides same day assessment for most patients and aims to refer them to other community services within seven days.
A couple who have been married for more than seventy years, and are both 95 years old, have been able to stay together at home, following support from the rapid response service.
Vera Wickham from Ely was referred to the service by her GP after an infected, swollen leg had left her unable to walk and feeling very unwell with a high temperature. Vera also suffers from chronic obstructive pulmonary disease (COPD), heart failure and high blood pressure, all of which has an impact on how she is able to cope at home. Vera and husband Len were struggling with daily tasks and activities.
Following the referral to the rapid response service Lucy Stewart, Community Matron, assessed the couple at home to consider what help and care they needed to be able to cope and recover at home together. Community matrons are advanced nurses with extended skills who support the assessment and care of people with complex needs. Lucy agreed a plan for them to receive the care they required to stay at home, as Vera didn’t need to be admitted to hospital.
Lucy liaised with the Vera’s GP to ensure she received antibiotics and on another visit assessed the effectiveness of the treatment. Vera also suffers from shortness of breath, even when she’s resting, which affects her mobility and appetite. Lucy consulted with the Trust’s specialist respiratory nurses, who suggested an increase in medication to reduce the fluid on her lungs.
Lucy explained: “One of the most important tasks during an assessment is to ask what the patient is most worried about. Vera doesn’t want to go to hospital because of her fears of dying there and leaving her husband alone. Once I understood this I could plan her care according to her wishes. After 73 years of marriage the Wickhams have become completely reliant on each other. It was vital to involve and communicate with both Vera and her husband inclusively.”
“The Wickhams are now on my regular caseload, although I’ve been discussing further support for them to ensure they can eventually manage without me. This may be from the wider community team. The couple are determined to remain independent and just want to remain together at home. If we can achieve this then we will have a successful outcome.”
Vera added: “Nothing is too much trouble for Lucy. She takes the time to listen to me, she explains everything and I trust her.”