New improved community service helping people to stay independent at home

11 November 2009, Abertawe Bro Morgannwg University Health Board

Investment in community-based health and social care staff in Neath Port Talbot is helping to keep local people in need of care where they want to be – out of hospital and in their own home.

 ABM University Health Board and Neath Port Talbot Council have worked together to make changes to the way they deliver community services to help people maintain their independence.
 
The newly designed Community Integrated Intermediate Care Service (CIIS) will substantially increase the number of patients who can receive their care outside of the traditional hospital setting.
 
Covering a whole range of adult patients, but with a particular focus on older people, the new CIIS team has recruited more staff to expand the service.
 
Occupational therapists, physiotherapists, nurse practitioners, healthcare support workers, contact officers, support workers and additional social work support have been recruited to join together with the existing Early Response Service (ERS) and reablement team to form CIIS.
 
The aim of the expanded service is provide early assessments and interventions to detect and prevent any deterioration in a patient’s medical and social situation. This should also prevent unnecessary hospital and care home admissions. It will support earlier discharge from hospital and reduce dependency on social care packages.
 
Pictured: Some members of the CIIS team. (left to right) Moira Vas – Physio, Jude Trotman – Healthcare Support Worker, Beth Jones – Physio, Becky Jones – Healthcare Support Worker and Chris Denharder – Occupational Therapist.
 
People who have suffered loss of independence after an episode of illness or a period in hospital will benefit, while referrals come from a range of health and social care professionals
 
Dr Firdaus Adenwalla, Consultant Physician, said:
 
“We’ve looked across our services at how best we can deliver care to the elderly and other adults.
 
“The reality is that older people in particular require more integrated services than can be provided on acute medical wards and it’s time to move away from the traditional view of a hospital being the only place we can deliver this type of care.  
 
“We know that those patients who receive rehabilitation in a less acute setting tend to become more independent and need less ongoing support packages.”
 
The Neath Port Talbot CIIS team, although mainly community-based, are based at Cimla Hospital where all referrals are received through a single referral point to provide a more responsive and streamlined service for patients and referrers.
 
There is also a base in the new Port Talbot Resource centre where the team can liaise with GPs and other services.  There are strong links with NPT Day Hospital where patients can access early specialist medical assessment and receive specialist care from day hospital staff if required. CIIS will soon operate seven days a week in NPT.
 
“For the first time all our resources will be pooled together and we’ll have a one-stop services. Staff can look at a patient’s care needs together making the service a lot more responsive,” added Dr Adenwalla.
 
“Our intermediate care service is introducing a number of developments that will further prevent unnecessary hospital admissions, supporting early and safe discharge from hospital and managing patients in the best way possible.”
 
The CIIS team was formed just last month and the staff are already noticing the benefits.
 
Physiotherapist Moira Vas is one of the newly recruited members of the team.
 
She said:
 
“We work with a number of different community services and my role is to go into people’s homes and decide on functional goals that might help them stay within their own community rather than hospital.
 
“We work on those goals with other members of the team, such as occupational therapists and support staff.
 
“We give patients exercise programmes, mobility exercises or aids for the home.
 
“Because our team is so intense we can really provide a lot of help and see big differences in our patients.”
 
Heathcare Support Worker Jude Trotman commented:
 
“Working together makes things easier because we can discuss patient needs as a team.”
 
The CIIS service has also started to roll out in Bridgend County Borough and is already underway in Swansea.
 
Contacts for further information:
 
Audrey Roach, Deputy Head of Physiotherapy and CIIS Implementation Lead, Tel 01656 754354.
 
Dr Adenwalla, Consultant Physician Day Hospital NPTH, Tel 01639 862603.