In West Suffolk, efforts to prevent unnecessary emergency admissions to hospital do not just take place in the A&E department. The Early Intervention Team also works in the community to support patients who hit a health and social crisis that does not require medical treatment in a hospital. Often the team supports frail elderly or clients with long term conditions.
The team crosses health and social care providers, as well as the voluntary sector. The team consists of community nurses, social workers, occupational therapists, physiotherapists, rehabilitation assistant practitioners, re-ablement support workers (carers) as well as support workers from Age UK Suffolk and a carer link worker from Suffolk Family Carers. Together, they provide a “one stop shop” to help people retain their independence and avoid hospital admission when it is unnecessary. The team also links closely with the Dementia Intensive Support Team. The team’s activity takes place in the community and it is very much a community facing service.
For example the team of community nurses and health care assistants work holistically within the EIT providing a 24 hour service 365 days a year in the community. Their main role is admission prevention, providing a short term service to keep the patients at optimum health and enabling them to remain in their own homes. They support patients and their families with palliative and ‘end of life’ care as well as any crisis response requiring nursing involvement. This may involve interventions such as initiating home IV, syringe drivers and urgent wound care. They liaise closely with the Home IV therapy team and the district nurse teams as well as hospices and care homes, and look forward to closer working with the GPs.
Integrated working enables the team to help support someone in crisis. For example, someone may have a urinary tract infection, causing them to be unsteady on their feet, struggle to manage personal care or meals. Using different skills across the team, the Early Intervention Team can prescribe equipment, provide care to re-enable, support with shopping, housework and refer on to organisations for proactive on-going support, as needed.
This cross-disciplinary and cross-boundaries approach helps ensure our patients have the support they need, when they need it, to help manage a crisis.
For more information: Gareth Blissett, Team Lead Early Intervention Team, West Suffolk NHS Foundation Trust