The trust’s urgent community response (UCR) services
provide a person-centred approach to optimise independence and confidence, enable recovery, prevent
a decline in functional ability and reduce the risk of readmission
to hospital.
Within UCR there are three teams working closely together but providing very different care.
Home First
Home First is an exclusive service to support the trust’s patients to be discharged from hospital by providing short-term care and reablement in their homes.
Ultimately, the care the team provides ‘bridges the gap’ until social services arrange a package of care or long-term support is no longer required.
At 8am senior occupational therapist Nikki Calvert goes through new referrals and looks at current caseloads.
The Tees team is currently caring for 14 people and two new referrals have come through from The James Cook University Hospital.
Within the team there are two physiotherapists and one occupational therapist who work alongside assistant practitioners and senior integrated support assistants.
At 11am Nikki assesses her first patient, who was discharged yesterday and requires support once a day to help with personal care tasks.
Nikki then travels to do another initial assessment, this time for a patient requiring support three times daily.
As well as gathering subjective information, she completes an assessment of the
patient’s mobility.
After lunch she catches up with the team, it is generally in the afternoon that updates will have been provided by social workers with details of when care providers will be taking over.
Plans are reviewed and staff feed back to the therapists if there have been any issues during visits.
The therapists visit patients to review mobility, transfers or complete functional assessments such as bathing – if indicated that there has been a change in ability after initial assessment.
Before clocking off at 8.30pm, Nikki has reviewed this morning’s caseload and has discharged a patient that no long requires support.
UCR services
The urgent community response (UCR) team has replaced the old rapid response and rapid therapies services in Middlesbrough, Redcar and Cleveland and the fast response service in Hambleton and Richmondshire.
The 24-hour service is for patients, registered with a GP in the area, who have an urgent care need (required within two hours).
The two-hour response is designed to reduce avoidable hospital admissions, while ensuring patients get the urgent care they need from the comfort of their usual residence.
Today community nurse Karl Sergent is on the 10am to 10.30pm shift.
He’s only just walked through the door when a patient with a blocked catheter refers themselves to the service.
Seconds later, another blocked catheter referral comes through from a local GP.
When it comes to patients with blocked catheters, the team sees the patient within one hour of receiving the call.
While out, he receives another GP referral but this time it’s relating to a palliative care patient. End-of-life patients have multidisciplinary teams caring for them, to ensure that there are no gaps in care and that everyone is aware of any changes in health, medication and care requirements.
By 12noon he returns to base for a quick lunch break, but that doesn’t mean he switches off – throughout he keeps an eye out for other urgent referrals.
Throughout the rest of his shift, Karl helps several patients with blocked catheters before doing some discharging referrals and handing over to the night office.