What is this service?
This team works with older people and those who have been identified as struggling with long term health issues, making sure they get the right care and support they need to continue to live independent lives.
The team is a central point of contact between patients and the health and social care services.
The aim is to reduce avoidable hospital admissions, support patients to leave hospital earlier and, crucially, help patients to remain independent at home for longer.
Where is this service?
Currently this team is based in offices at Clifton Moor in York
Who is it for?
The team currently provides around 9,000 visits to patients in their own homes each year. A large part of this work is about identifying their needs early, so that we can be prepared and avoid crisis situations whenever possible.
The team works with older people and those who have been identified as struggling with long term health issues, making sure they get the right care and support they need to continue to live independent lives.
Who provides this service
The team is organised into neighbourhoods and around Primary Care Networks (GP practices working in teams) as much as possible, to meet individual and population health needs. It links closely with Primary Care, voluntary sector, hospital, community, mental health, and other services.
It includes Frailty Nurses, GPs with a specialist interest in Frailty, Care Navigators, Occupational Therapists, Physiotherapists, Social Prescribers, Dieticians, Healthcare Supports (Healthcare Assistants), Nursing Associates, Therapy Assistants and Paramedics.
When is this service provided?
Seven days a week.
How to access the service
Via your GP practice
Benefits for our patients
- Making sure patients have a named nurse and have access to call the team five days a week, if needed. (The service does run for seven days a week).
- Avoiding hospital admissions by picking up on patient physical, mental or social health concerns earlier and responding to individual needs.
- Providing a two-hour Urgent Community Response alongside the York and Scarborough Hospitals NHS Foundation Trust Community team to prevent admissions to hospital in crisis situations.
- Liaising with patients’ own GP to support patients at home, when needed.
- Providing routine review of all patients on its register to check for signs of increasing frailty and to offer referrals and access to services, as needed on a personal basis.
- Supporting with discharge from hospital and supporting people at home, so they can get out of hospital quicker.
- Working with community teams to help patients who are well enough medically to leave hospital, but their discharge has been delayed.
- Reviewing and supporting patients, once they come home to reduce the chance of readmission to hospital.