Our care – supporting people to be well, independent and at home

Mary's story

Since 2015 when this Trust became an ‘integrated care organisation’ we have been changing our health and care services and the way we provide care. Our aims are:

  • to give people more say in decisions about their care;
  • to support people to manage their own health and wellbeing;
  • to develop a more flexible workforce which has the right skills to provide the care people need, when and where they need it;
  • to reduce inequalities in health and care, so that people have the same access to safe, high quality care no matter where they live; and
  • to remain financially sustainable, ensuring that we can continue to provide the services our local communities need, now and in the future.

Our model of care has been developed in order to achieve the above aims, to support people to be well, independent and at home. Wherever it is possible and practical we aim to deliver care and support to people close to where they live, with easy access to a hospital bed when this is needed. The following pages set out how we are doing this.

Community Health and Wellbeing

“Our strengthened integration is reflected in the people who are in our community teams. These teams are made up of people from a number of organisations and agencies as well as staff from our Trust.”

Focus on wellbeing

Intermediate Care Team

A corner stone of our community provision are our Health and Wellbeing Teams, who are based in each of our five localities in Health and Wellbeing Centres.

Our Health and Wellbeing Teams provide truly integrated care, with staff across the health and care sector along with our Trust’s voluntary partners and the independent sector (eg care and nursing homes) working more closely than they have before. Together, they provide care and support services which meet a wide range of health and wellbeing needs of local people.

Teams include: GPs, nurses, therapists, social workers, care co-ordinators and pharmacists along with 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 of people in a joined-up way. By coming together in a team they are able to share information, and co-ordinate the most appropriate care that meets people’s individual needs. Together they focus on:

  • preventing ill health (both physical and mental);
  • supporting people to look after their own health; and
  • identifying health and care needs sooner.

The Health and Wellbeing Centre is where the Health and Wellbeing Team is based, and provides people easy access in one place to a number of services.

Please visit the relevant locality pages for details of what services are available.

David's story

Wellbeing Co-ordinators

Supporting people to be well and independent means that we do not just focus on illness, but also on the things people need to stay well. Our Wellbeing Co-ordinators are trained staff employed by our voluntary sector partners who work in each locality as part of our Health and Wellbeing Teams.

Keeping well and preventing illness

HOPE Programme

HOPE (Helping Overcome Problems Effectively)

HOPE is a six-week programme to help people to develop 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.

Supporting recovery

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. Intermediate Care 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 seven days a week.

Referrals to Intermediate Care are from GPs, community and hospital teams.

Rapid Response is an immediate, short-term (up to seven days) personal care and sitting service available to adults who have an acute physical health crisis or a sudden breakdown in care. The service aims to prevent admission to hospital or to a residential or nursing home, and is often provided in addition to Intermediate Care. It is also available to people leaving hospital particularly at the end of life. The service is provided by support workers who visit during the day from 7am to 10pm, but overnight sitting can be arranged.

Referrals to Rapid Response are from GPs, community and hospital teams.

Specialist support in the community

Medical Admissions Avoidance Team

Medical Admissions Avoidance Team (MAAT) is a team of nurses who provide care to people in their own home which would have normally required a hospital stay. This includes 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 days or even weeks. The MAAT team are able to give these treatments in the community, either in a person’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 go into hospital altogether.

The MAAT team work closely with hospital and community teams, helping to identify people who they can care for at home. They work with Torbay Hospital’s microbiologists to identify where patients can receive different kinds of antibiotics, which can be delivered away from hospital.

Referrals to the MAAT team are made by GPs, community and hospital teams.

Locality Pharmacists are members of locality Health and Wellbeing Teams. As well as doing medicine reviews for people who are house-bound and unable to get to see their GP or community pharmacist, they also work particularly closely with Intermediate Care teams and care homes, to support people who have multiple long term conditions and who are therefore taking a number of different medicines. They also ensure that any unnecessary medicines are discontinued. Locality pharmacists also educate people about their medicines, helping them to understand what their medicine is for and why it is important to take them correctly.

Locality Pharmacists therefore 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 living with long term conditions, either at home or in another community setting. They help 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.

Specialist Nurses provide treatment, education and support to people so that their condition doesn’t get worse, or improves where possible. They work with people to develop care plans so that they know what to do if their condition worsens, with the aim of avoiding a crisis or hospital admission. They help people to feel more confident and in control of their own health and wellbeing.

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