Our care – Supporting people, to be well, independent and at home
These pages contain information that sets out how we are changing the way we support people to be as well and independent as possible. Some of these services have been in place for some time but others are newer. We are constantly looking at how we can improve the way we care for people and we continue to focus resources into caring for people at home and in local communities. Our aim is to support people to be at home whenever it is appropriate but also to ensure that a hospital bed can be accessed easily when somebody needs this. Acute medical bed-based care would normally be accessed at Torbay Hospital and community medical bed-based care at Dawlish Hospital. We also purchase bed-based rehabilitation care via local care homes when it is needed. Urgent care can also be accessed at Dawlish Hospital for those who suffer a minor injury and emergency care can be accessed via 999 or attending the Emergency Department at Torbay Hospital.
A corner stone of our community provision are our Health and Wellbeing Teams who are based in each of our localities. In Coastal the team is based in Teignmouth but covers the whole locality of Teignmouth and Dawlish. The team ensure they know what is important to people and that they can access the care and support they need to stay well; no matter where they may live.
Community Health and Wellbeing
Health and Wellbeing Centre
In Coastal, we have developed a Health and Wellbeing Centre which is based in Teignmouth Hospital and would move to a new site if this was the option decided on. The Health and Wellbeing Centre is where a range of health and wellbeing services, provided by a number of organisations and agencies, are brought together. This provides easy access in one place to a number of services which support the health and wellbeing of local people. Local Health and Wellbeing Teams use the centre as a base from which to deliver services to the community. The services currently provided include outpatients clinics and services such as physiotherapy, podiatry and audiology.
Health and Wellbeing Teams
Health and Wellbeing Teams are made up of a number of organisations and agencies working together to provide care and support services which meet a wide range of health and wellbeing needs of local people. They include GPs, nurses, therapists and social workers as well as professionals from independent and voluntary sector organisations. Their aim is to provide the best possible care for local people by looking at the individual needs off people in a joined-up way. By coming together in a team they are able to look at all the needs of a person and provide care that meets their needs. There is a greater focus on prevention of ill-health (both physical and mental); supporting people to identify health and care needs sooner. There is also a greater emphasis on supporting people to look after their own health and wellbeing with the right support.
Supporting people to be well and independent means that we do not just focus on illness we focus on what helps them to stay well. To support this we have Wellbeing co-ordinators in each locality who work as part of our Health and Wellbeing Teams. Wellbeing co-ordinators are trained staff, employed by the voluntary sector, who work with individuals to help them identify what is important to them. They do this through asking people about their goals and aspirations for daily life; then support those individuals to achieve these goals, connecting with groups and activities within their local community which help them to feel less isolated and more fulfilled. Wellbeing co-ordinators are able to link people to the wide variety of community and voluntary sector resources which can add value to their lives; and which they otherwise may not even be aware of. This could be anything from transport to enable someone to go shopping independently, to a knitting club, or even walking football for men with heart and other conditions. Referral to a Wellbeing Co-ordinator can be made via the GP or community team within the locality, or individuals can self-refer to the service.
Rehabilitation, Reablement and Recovery
Unfortunately even with services in place to support people to be well there are times when they do become unwell. Our services must also focus on supporting people during periods of ill-health and helping them to be well again and to be able stay independent as possible.
Intermediate Care can be provided for a limited period of time, to people who need extra support and care following a period of ill health including supporting people to come home quicker following a stay in hospital. The teams are made up of nurses, therapists and social workers, with dedicated medical and pharmacy support; enabling them to manage people who have complex needs, outside of hospital. The service operates 7-days a week.
Rapid Response is available to adults who have an acute physical health crisis or a sudden breakdown in care, where, with appropriate support and services, it would be possible for them to stay in their own homes. Rapid Response is also available to support discharges from hospital, particularly for patients at the end of life. The service provides an immediate short-term care (up to a maximum of 7 days), with the aim of preventing admission to hospital or to residential / nursing homes. The services are provided by support workers who visit during the day (from 7am – 10pm) – where necessary an overnight sitting service can be arranged.
Specialist Support in the Community
The Medical Admissions Avoidance Team (MAAT) is a team of nurses who provide care to people in their home which would have normally required a hospital stay. This can include treatments such as intravenous fluids or antibiotics, anti-coagulant drugs before surgery, or giving certain injections. Treatments like this require frequent monitoring and specialist nursing skills to deliver. Previously, patients requiring them would have been admitted to hospital for the treatment – which could have been anything from days to weeks. The MAAT team are able to deliver these treatments in the community; either in an individual’s own home, in a care home, or in a community clinic. This enables people to return home sooner after an inpatient stay, or to avoid having to come into hospital altogether. The MAAT team work closely with hospital and community teams helping to identify people who they could care for at home. They also work with our Microbiologists to identify where patients could receive different kinds of antibiotics, which could be delivered away from hospital. Referrals to the MAAT team can be made by GPs, community teams and hospital teams.
Locality Pharmacists are part our locality Health and Wellbeing Teams who help support people with complex needs in the community. Locality pharmacists work particularly closely with our Intermediate Care teams and care homes and particularly with people who have multiple long term conditions; and those who have to take a number of different medicines. Pharmacists review an individual’s medicines to help reduce the risk of ill-health as a result of taking multiple medicines, which may sometimes interact with each other causing people to feel unwell. They also ensure that any unnecessary medicines are discontinued. In addition, locality pharmacists can provide support and education to people around their medicines; helping them to understand what each medicine is for and why it is important. They can arrange special blister packs to help people take the right medicines at the right time, or find alternative solutions for people who have difficulty in swallowing tablets. Locality pharmacists play a vital role in reducing the adverse effects of medicines, ensuring people get maximum benefit from their medicines and supporting people with complex needs outside of hospital.
Specialist Nurses are community-based and have additional training and experience to care for people with long-term conditions. They deliver care to people at home or in community clinics and can offer advice and support on managing a long-term condition. The aim is to provide treatment , education and support for people living with long-term health conditions; so that their condition doesn’t get worse or improves where possible. They work with individuals to develop care plans so that they know what to do if their condition gets worse; with the aim of avoiding a crisis or hospital admission. They also help people to feel more confident and in control of their own health and wellbeing. Our specialist nurses support people with a wide range of conditions, including Chronic Obstructive Pulmonary Disease (COPD), Epilepsy, Diabetes, Heart Failure, and Parkinson’s Disease. They also specialise in tissue viability (skin and soft tissue wounds such as leg ulcers, pressure sores and surgical wounds) to prevent infection and promote recovery
Prevention and Supported Self-care
HOPE (Helping Overcome Problems Effectively)
HOPE is a 6-week programme to help people with confidence, skills and knowledge to manage their health conditions. The programme not only provides tools and techniques but also peer support; connecting people within the local community who share lived experience of health and wellbeing issues. The programme supports people to identify goals and strengths, empowering them to take greater control of their wellbeing, and focus on what matters to them. By connecting people with others in their local area, the programme aims to help them build a network of support which they can then sustain after the course has finished.
Volunteer Lifestyles Screening
Torbay Hospital is the first hospital in the South West to provide a Volunteer Lifestyles Screening service. Volunteers are trained to provide lifestyles screening and brief advice to people across various areas of the hospital, including the Emergency Assessment Unit (EAU) and pre-assessment wards. Volunteers can provide information and signposting for smoking, alcohol, physical activity, debt, carers support and nutrition. They can also refer patients who may need extra help and support directly to other services for more specialist advice.