The Community Advanced Clinical Practitioner (ACP) and Matron Team provide a holistic, home based service for patients with complex health needs who are at risk of hospital admission or, who have already experienced recent hospital admissions. They work with each individual and their carers/families to understand health and wellbeing needs and explore options for treatment and support. This might involve further tests, changes to medications or referral /liaison with other services to ensure a co-ordinated approach to treatment.
The ultimate aim is to improve well-being and prevent avoidable hospital admissions by planning for the future and promoting the right care taking place at the right time. Patients will be offered an Enhanced Case Management (ECM) plan to maintain wellbeing and actions agreed with the patient/carer to take if their health is worsening. Links may be offered to the Crisis (Urgent) Response Team who work alongside our service responding to urgent calls to prevent admission. |