Cambridgeshire Community Services NHS Trust is running a one year community Rapid Response pilot service for patients registered with GP practices in the Ely area and Wisbech. The aim is to ensure that unwell older people get the urgent support they need to be cared for at home, when they need it.
The multi-disciplinary service includes nurses, occupational therapists, physiotherapists, social care managers, a Consultant Geriatrician, pharmacists, multi-skilled healthcare assistants and others. The service provides same day assessment for people in crisis and works as part of the wider Community Service referring on within seven days once stabilised.
A couple from Ely who have been married for more than seventy years, and are both 95 years old, have been able to stay together at home, following support from the Rapid Response service.
The lady of the couple was referred to the service by her GP after an infected, swollen leg had left her unable to walk and feeling very unwell with a high temperature. Following the referral to the Rapid Response service Lucy Stewart, Community Matron, assessed the couple at home to consider what help and care they needed and agree a plan to be able to cope and recover at home together.
The Community Matron role has changed from the case management model for patients with long term conditions to rapid advanced clinical assessment. Joint working with other health care professionals is integral, including Physiotherapy, Occupational Therapy, intermediate carers, Pharmacists and GPs. Although the 6Cs began as a nursing initiative, the principles have been embraced by the whole multidisciplinary team as part of its culture.
Lucy explained: “One of the most important tasks during an assessment is to ask what the patient is most worried about. In this case, the patient didn’t want to go to hospital because she feared dying there and leaving her husband alone. Once I understood this I could plan her care according to her wishes.
“After 73 years of marriage the couple had become completely reliant on each other. It was vital to involve and communicate with both the patient and her husband inclusively.”
Mandy Renton, Chief Nurse at Cambridgeshire Community Services NHS Trust, said:
“The patient has fed back that nothing is too much trouble for Lucy. She takes the time to listen and explains everything.
“The Rapid Response service was launched in November 2013. Data from November shows 156 acute hospital admissions avoided out of a total of 347 referrals. A staggering 45% of referrals were enabled to stay at home by the Rapid Response service where otherwise they would have been admitted to acute care.”
Mike Passfield, Head of Nursing (Unplanned Care) Cambridgeshire Community Services NHS Trust, said: “Although the 6Cs started as a Nursing & Midwifery model, the Rapid Response team including our Physiotherapy, Occupational therapy and Pharmacist members have actively adopted the model and are committed to improve the quality and the experience of the patients, showing that the 6Cs values and behaviours can be practised by all clinicians to ensure safe care is delivered to patients.”
Sam Sherrington, Head of Nursing and Midwifery Strategy at NHS England, said:
“This heart-warming story shows an integrated team delivering the values and behaviours of compassion, especially when patients and families are anxious, vulnerable, and need our care and compassion the most. Respect and the promotion of dignity are at the centre of the care they need and which Lucy and her team so clearly provide.”
If reading this makes you think that you too have a great story to tell, visit http://www.6cs.england.nhs.uk/pg/groups/66586/Celebrating+success/