8-Community medicine Flashcards
When patients are not unwell enough to be in an acute hospital, but not well enough to go back home or back to a nursing home where can they go
intermediate care and reablement
intermediate care
a type of short-term support that aims to help you be as independent as possible. It can be provided in a community hospital, care home or your own home (ICT)
goals of intermediate care
optimise health and reablement
- physiotherapist
- OT
- social care involvment
reablement
Reablement has similar aims to intermediate care but focuses on helping you to learn or re-learn skills necessary for daily living. Social care staff support you at home by observing and guiding you to complete tasks such as washing, dressing and preparing a snack for yourself, rather than doing these tasks for you. The aim is to help rebuild your skills, improve your mobility and help rebuild your skills and confidence.
timeframes for intermediate care and reablement
receive up to 6 weeks care after hospital discharge for free Intermediate care and reablement services normally last no longer than 6 weeks, but can be as little as 1 or 2 weeks if you achieve your goals within this time.
timeframes for intermediate care and reablement
receive up to 6 weeks care after hospital discharge for free Intermediate care and reablement services normally last no longer than 6 weeks, but can be as little as 1 or 2 weeks if you achieve your goals within this time.
intermediate care in community hospital
Intermediate Care/Rehabilitation Unit
A local facility providing beds and associated clinics and therapy in order to promote independence, avoid admission to a DGH (step up) and reduce stays in a DGH (step down). These units or hospitals typically focus exclusively on rehabilitation, and do not provide other services. These may be standalone units, or within a nursing home.
MDT in community hospitals
- doctor
- nursing care
- physio
- OT
- nutritionist
- discharge coordinator
is it appropriate to discharge?
describe the concept of rehabilitation
Rehabilitation is a process of person-centred assessment, treatment and management by which the individual (and their family and carers) are supported to achieve their maximum potential for physical, cognitive, social and psychological function, participation in society and quality of living.
5 Rs of rehabilitation
- Realisation of potential
- Re-ablement – to maximise the functional independence
- Resettlement – to provide safe transfer of care
- Role fulfilment – to establish personal autonomy
- Readjustment – to adapt to new lifestyle
good rehab serbice will
- Optimise physical, mental and social wellbeing and have a close working partnership with people to support their needs.
- Recognise people and those who are important to them, including carers, as a critical part of the interdisciplinary team.
- Instil hope, support ambition and balance risk to maximise outcome and independence.
- Use an individualised, goal-based approach, informed by evidence and best practice which focuses on people’s role in society.
- Require early and ongoing assessment and identification of rehabilitation needs to support timely planning and interventions to improve outcomes and ensure seamless transition.
- Support self-management through education and information to maintain health and wellbeing to achieve maximum potential.
- Make use of a wide variety of new and established interventions to improve outcomes e.g. exercise, technology, Cognitive Behavioural Therapy.
- Deliver efficient and effective rehabilitation using integrated multi-agency pathways including, where appropriate, seven days a week.
- Have strong leadership and accountability at all levels – with effective communication.
- Share good practice, collect data and contribute to the evidence base by undertaking evaluation/audit/research.
discharge referral routes from community hospital
1) Reablement
2) ICT
3) Reablement andICT
4) Adult social care (ASC)
* home with package of care
* 24-hour care (residential home placement)
* DTA
5) NHS continuing health care
* high level nursing needs- residential
ICT
intermediate care team
Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent to hospital. Intermediate care (01) helps people to avoid going into hospital or residential care unnecessarily. helps people to be as independent as possible after a stay in hospital.
- short term nuring
- OT/ physio support
NHS contuing healthcare
NHS Continuing Healthcare (CHC) is a package of ongoing health and social care that is arranged and funded solely by the NHS, where the individual meets specific criteria laid down by the DHSC. For adults, this funding is offered to meet health and associated social care needs that have arisen as a result of disability, accident or illness.
Social care and discharge
social care can help with payment for residential home if patient is deemed financially unable to pay themselves
- this will involve investigation into patients finances
- patients will have less choice where they go
Social care and discharge
social care can help with payment for residential home if patient is deemed financially unable to pay themselves
- this will involve investigation into patients finances
Discharge to assess process
Where people who are clinically optimised
and do not require an acute hospital bed, but may still
require care services are provided with short term,
funded support to be discharged to their own home
(where appropriate) or another community setting.
- Assessment for longer-term care and support needs is
then undertaken in the most appropriate setting and
at the right time for the person.
- up to 6 weeks (free)
- then conclusion will be come to regarding what the patient needs exactly
specialist teams and care services to support older person at home with complex comorbidities and long term conditions
Home visits by doctor
Nursing needs
- medication admin
- clean and redress wounds
Caring needs
- Help with getting dressed, washing and personal care
- Help using the toilet
- Washing and personal hygiene
Physio/ OT
- to support living alone/ ADLS
Podiatrist
Cleaning support
Financial support
Meals on wheels
Long-term care
involves a variety of services designed to meet a person’s health or personal care needs during a short or long period of time. These services help people live as independently and safely as possible when they can no longer perform everyday activities on their own.
Long-term care
involves a variety of services designed to meet a person’s health or personal care needs during a short or long period of time. These services help people live as independently and safely as possible when they can no longer perform everyday activities on their own.
intermediate vs interim care
-
Intermediate care- between hospital and community (6 weeks)
o E.g. corby or isebrook -
Interim care- away from hospital (DTA)
o Needs to be a 24 hour setting to assess needs
o Up to 6 week assessment and then make a decision on their needs (DTA)
