Special teams for patients in hospitals out of Lincolnshire

Jenny Hinchliffe ANL-141023-113554001

Jenny Hinchliffe ANL-141023-113554001

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HEALTH MATTERS: A monthly column by Jenny Hinchliffe, Head of Clinical Services for the South at Lincolnshire Community Health Services NHS Trust

Nationally this year we have seen unprecedented pressures within the health and social care community this winter. Within Lincolnshire Community Health Services NHS Trust (LCHS), we have risen to the challenge to support the people that are medically fit for discharge to return to the community.

Patients can be supported on discharge in a variety of settings

This has been supported by our Assertive In-reach Teams. We now have teams in Peterborough City Hospital, Queen Elizabeth Hospital, King’s Lynn and United Lincolnshire Hospitals Trust. The staff are employed by LCHS and work with any patients in hospital who are registered with a Lincolnshire GP.

The Assertive In-reach Team are experienced nurses who work with the acute hospital team to identify those patients who are medically fit for discharge. The team then work with the patient, their family and carers to arrange a safe discharge into the community.

Patients can be supported on discharge in a variety of settings, which include Johnson Community Hospital Spalding. Our Independent Living Team also supports patients who are discharged into a local care home or to their own home.

The Independent Living Team consists of therapists, care staff and nurses support patients to gain their independence and confidence following discharge form hospital.

This year LCHS has been successful in securing additional funding to enhance the team due to the huge success it has made in reducing the number of patients that are medically fit for discharge and cannot be discharged because of ongoing need.

This is enabling us to have a proactive approach in identifying patients registered with a Lincolnshire GP in hospital and to work with the wards to ensure we facilitate the discharge as soon as the patient is medically fit. We are also able to educate ward staff of the services which are available in Lincolnshire.

Ensuring patients are assessed as individuals is key to the success of the Assertive In-reach staff. This includes assessing patients nursing needs, mobility needs and activities of daily living, and ordering any equipment that is required or making arrangements for adaptations to be made in order for the patient to live as independent and full a life as possible.

The Assertive In-reach teams work with colleagues across Lincolnshire Community Health Services and other health and social care colleagues to ensure the transfer from acute care to the community is a smooth transition. With consent from the patient, records are shared from the Assertive In-reach Team to the Community Team to reduce duplication of assessments for the patient.