This includes those residents registered with City & Hackney GPs and residents without a GP.
The overall functions of the service are to improve or maintain health, and promote independence and self-care. It also strives to contribute to hospital admissions avoidance and disease prevention, achieved by working in partnership with patients, their carers, GPs and other health and social care professionals to ensure that, whenever possible, care is maintained at home.
The ACN service is made up of several component parts:
- integrated community matrons and district nursing teams
- specialist services including: tissue viability; continence and palliative care; clinical nurse specialists for multiple sclerosis and Parkinson's disease;
- the discharge planning and continuing care teams and the nursing element of the First Response duty team (FRDT).
District nurses and community matrons operate as an integrated team based service organised around the four localities, with each locality team aligned covering the patient population of the GP practices within the locality.
Community matrons are highly skilled nurses who support patients with long term conditions by providing patient focused care, navigating the patient through care pathways across primary, secondary and social care interfaces. They also work closely and autonomously with stakeholders to maximise quality of life and improve health outcomes for patients, as well as promoting understanding of their health conditions and encouraging self-management through the use of technology eg. TeleHealth.
The specialist services work with the wider teams at Homerton to ensure community based services are complementary to the existing work of the mainstream services within the hospital. The specialist nurses run nurse-led clinics jointly with some of the specialist teams in the hospital and in the community. eg Parkinson's disease, multiple sclerosis.
The discharge planning/continuing care team aids complex discharges from the hospital back to either their own home or into long-term care facility where necessary. The team is also involved in the assessment of continuing care patients and arrange for suitable placements according to the needs and wishes of the service user. The team also ensures that these placements are clinically safe and meet the requirements of the individual patients.
Characteristics of the adult community nursing services include (but are not exhaustive) the following.
- Comprehensive assessment of patients in order to develop an integrated plan of care in partnership with patients and their family.
- Co-ordination and management of nursing care to house bound patients or patients in residential homes.
- Provision of clinic based services to mobile patients, for example leg ulcer and continence clinics.
- Provision of continuing care, rehabilitation, and management of long term conditions eg diabetes and COPD.
- We offer support and advice to patients (and their carers) in relation to long-term conditions management, ongoing care and post-operative care.
- Provision of health promotion, education and advice to patients in order to maintain health and wellbeing, working in partnership with other professionals and agencies, eg GP, specialist teams, therapy teams, social services and voluntary agencies.
- We assess for specialist nursing equipment that might be required by patients in their homes to maintain comfort, aid treatment and minimise further health problems, eg specialist beds, mattress & cushions.
- We provide palliative care for those who are terminally ill, including end of life care and bereavement support for carers.
- We provide end of life care.
- Provision of continence assessment and support, and ensuring supply of continence pads are maintained as required by patients.
- Wound assessment and care management of ulcers and other types of wounds
- Supporting the management and administration of medicines.
Palliative/end of life care
The ACN service is staffed by a workforce that is competent in the delivery of palliative/end of life care including skills in communication, assessment and care planning, symptom management, advance care planning, cultural awareness and the promotion of dignity in line with the national common core principles and competencies for end of life care that have been produced by Skills for Health and the national End of Life Care programme.
The clinical operational managers, as the case managers, provide coordinated package of care for palliative patients. They work closely with patients and their families to offer help and support to help them achieve their choice of place for care and death.
They discuss advanced care planning to help patients make final preparation for the final stage of their illness and after care. The DN case managers can request specialist equipment or adaptation required for the home where needed including: specialist bed, mattress, cushions, etc, and equipment that would make patients as comfortable as possible at home.
The district nurses support palliative patients in the different stages of their condition, enabling them achieve best quality of life throughout. They visit patients at home to deliver nursing care and advise on the management of their condition and, especially, at the end of life stage when they may require more intensive and frequent visits to manage symptom control.
Within adult community nursing there is a specialist palliative nurse who operates from St Joseph’s Hospice and forms part of the specialist palliative team. The community nurses work closely with many other health care professionals including GPs, allied health professional teams, specialist palliative teams at Homerton Hospital and St. Joseph’s, Marie Curie Service, social workers and other voluntary agencies to provide quality care to help patients and their families/carers cope better and adjust to the changes in their lifestyle.
The community nurses are supported by the palliative team at St. Joseph's and the hospital. They also discuss patients’ progress with their GPs to agree the best possible plans of on-going care.
The adult community nursing teams work in collaboration with other partners and agencies including GPs, the hospital, allied health professionals, children & families service, the mental health Trust, community services, social services, local authority, St Joseph’s Hospice, higher education institutions, ambulance service, and other voluntary groups.
Multidisciplinery meetings are held to draw up joint care plans ensuring the provision of a high quality and seamless service.