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
What is intermediate care?
a type of short-term support that aims to help pts be as independent as possible. It can be provided in a community hospital, care home or pts own home (ICT)
What are the goals of intermediate care?
optimise health and reablement
- physiotherapist
- OT
- social care involvement
What is reablement?
similar aims to intermediate care but focuses on helping pts learn / re-learn skills necessary for daily living.
Social care staff - support at home by observing / guiding tasks e.g. washing, dressing, preparing food. NOT doing it for pts.
AIM: rebuild pts skills, improve mobility and help pts with their skills and confidence.
What are the timeframes for intermediate care and reablement?
free Intermediate care - up to 6 weeks care after hospital discharge
Reablement services - normally no longer than 6 weeks, but can be as little as 1 or 2 weeks if pts achieve their goals within this time.
what is 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 focus on rehabilitation, do not provide other services. These may be standalone units, or within a nursing home.
Who is involved in an MDT in community hospitals?
doctor
nursing care
physio
OT
nutritionist
discharge coordinator
When is it appropriate to discharge in community medicine?
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
What are the 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
What are the features of a good rehab service ?
- 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.
What are some of the possible 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
What does ICT (intermediate care team) do?
Intermediate care services are provided to pts post hospital / pts at risk of being sent to hospital.
- To avoid admission to hospital or residential care unnecessarily.
- Help pts to be as independent as possible after a stay in hospital.
- short term nursing
- OT/ physio support
What is NHS continuing healthcare?
A package of ongoing health and social care that is arranged and funded solely by the NHS.
Pts must meet criteria laid down by the DHSC (dept of health and social care).
Adults - funding to meet health and associated social care needs that have arisen as a result of disability, accident or illness.
How does social care come into play when a pt is discharged from community hospital?
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
