I am delighted (if a little nervous) to have been asked to write this week’s guest blog. My name is Catriona Logan and I am the Divisional Director of Operations for Community and Intermediate Care Services (CIC).
My blog follows on nicely from Chief Operating Officer, Sharon Gilligan’s blog last week when she talked about the importance and success of teamwork. As the name suggests, the division of Community and Intermediate Care provides services which are generally outside of hospital settings and involve working with many different teams, both internally and externally to the Trust.
Imagine a healthcare system where patients don't have to be admitted to hospital but can receive care within the familiar walls of their own homes, or wherever they live. That's in essence what we aim to deliver – care where patients live and are usually most comfortable.
The care we provide across our services put the patient and their family and loved ones at the centre. It guarantees they are involved in decisions being made and they are comfortable with what is planned for them. We know that their well-being is connected with their environment, family, and daily routines, so this holistic approach, treating not just symptoms or conditions but the person as a whole, means the care they receive is personalised and tailored to their individual needs.
This is a very simplified way of describing a very complex system of care navigated and coordinated by the Intermediate Care Allocation Team (ICAT), which has the most comprehensive knowledge and access to the many different teams and organisations involved in keeping our patients supported – wherever they may be. However, I hope it shows a strong teamwork ethos all for the good of the patient.
ICAT provides a single point of access to health and social care professionals throughout east Lancashire. They are able to tap into a range of resources provided by both the NHS and local authorities, as well as commissioning specific services from the voluntary sector.
This means that anyone referring into ICAT – either clinical colleagues from the Trust, ambulance service or GPs - need only call one number to enquire about the services available to support a patient in their usual place of residence.
Working this way with multiple health and social care services, also provides us with a unique opportunity to identify potential health risks or declines in conditions early, so they can be addressed before they become more serious and a hospital admission is needed.
Over more recent years, we have developed a strong Intensive Home Support Service (IHSS) which operates 24/7, 365 days a year. It is a multi-disciplinary team of nurses, medics and therapists who assess, investigate and provide support to help avoid any unnecessary hospital admissions.
IHSS takes a ‘home first’ approach to reduce or avoid hospital admissions and attendances. They reach into the Emergency Department to support colleagues by identifying those patients that we can discharge directly from the department into our care.
On the wards the service also helps to prevent people staying for longer than they need to by providing Hospital at Home support to assist recovery. Once the patient’s condition is stable at home, the team can provide on-going monitoring and support, under the care of their GP.
Moving patients off wards and back to their homes or place of residence, frees up beds for those who’s care is more complex or urgent and aids patients moving through the hospitals.
A recent expansion to the service enables the team to focus on supporting care homes so patients stay at home to receive treatment, rather than experiencing an emergency admission via ambulance. The IHSS team has three fabulous care home nurses who act as the first port of call to provide advice, support and training to care homes across Pennine Lancashire.
Some patients who have had to be admitted to our wards, may find their health has deteriorated or changed significantly, meaning they are no longer able to return to their home. Our Integrated Discharge Service is there for them to make sure any care home placements are suitable and appropriate for their personal needs.
Care continues on discharge by our Care Home Allocation Service. Patients, families and the care homes are offered support to help with rehabilitation and to reduce the chances of readmission.
Having close contact with patients and the care homes they are able to pick up any early signs of a placement not working out. This reduces stresses and anxieties for the patients and families and enables additional support to be provided to the care homes where necessary.
The Care Home Allocation Service also works closely with multi-disciplinary teams on the wards to help them reach the right discharge decisions for our more complex patients. These are patients who will need additional or a higher level of support when they leave hospital.
Moving into the winter months, this complex wrap-around model of care becomes even more vital, as the demand for hospital services increases and the impact hits our Emergency Department.
As I read back over this blog, I release that I have only scratched the surface of the services provided by the Community and Intermediate Care Services. And to those of you who are not familiar with out of hospital care, it must seem like an intricate and interlaced range of teams and services – and you would be right!
My closing message from this blog is to encourage our clinician colleagues – either in the hospitals or out in the community - to use the Single Point of Access provided by the Intermediate Care Allocation Team. It is there to help you discuss the best care plans for our patients. And for patients, families and loved ones, I hope you are assured that the support the service provides, whether in hospital or at home, will keep you at the core of the high quality, safe, personal and effective care you receive.
Thank you for reading.
Catriona
