Integrated Community Teams

Make a referral

Patients are seen in their place of residence when they are unable to travel to the hospital or community clinic for physiotherapy as a consequence of their condition.

We treat adults aged 18 years and over, with physical and social problems, in order to improve everyday activities and to support them to live independently and safely in their own home.

Our occupational therapists are problem-solvers who empower people to take control of their lives by adapting household products so people can use them, teaching coping strategies and supporting them to take part in social activities.

We work as part of the organisation’s Integrated Community Team (ICT) which is made up of occupational therapists, physiotherapists, social workers, reablement workers and community nurses to work as one team to serve a local area. The role of local GPs is pivotal in this, together with our skilled teams based in our seven community hospitals across Gloucestershire. Our Integrated Community Team also works closely with our countywide specialist services, voluntary services and other care providers to provide assessments, treatment and support for people within the community.

Service locations

We aim to provide your care close to home or within your home. Most people are seen at home, and our occupational therapists will work with other members of the team to provide co-ordinated care. If you are in a community hospital however, you will be seen by one of our occupational therapists based there.

Please note: Occupational Therapy services at Cheltenham General Hospital and Gloucestershire Royal Hospital are provided by Gloucestershire Hospitals NHS Foundation Trust.

Our service

We work to help prevent emergency hospital admissions and readmissions and support people to live at home wherever possible. As part of this we aim to:

• prevent avoidable harm to older people such as falls
• improve access to the service, reducing waiting lists and increasing responsiveness
• encourage and support independence in daily activities
• place users and carers at the centre of our activities
• work in partnership with users and carers, the voluntary sector, other agencies and other sections and groups to achieve the best possible service.

We will do this by providing individual assessments and working with carers needs to help enable independence wherever possible. We will:

• provide specialist equipment to help with daily tasks
• manage the equipment on loan, including storage and maintenance, delivery, collection and fitting
• work alongside colleagues and partners from statutory and voluntary sectors to help support leaving hospital
• provide advice and information about disability for people using our service, carers and professionals
• conduct risk assessments (in line with Moving and Handling Regulations) and provide advice, equipment and instruction ehere needed.

Following an assessment, and potentially a period of reablement, we help to identify and provide major and minor adaptations to properties by making recommendations to environmental services for Disabled Facilities Grants (DFGs), Home Repair Assistance Grants and design in new and refurbished accommodation for disabled service users.

You may be in an interim bed after being discharged from Cheltenham General or Gloucestershire Royal Hospitals before you are fit enough to be discharged home. In this case, you will be seen by one of occupational therapists from your local community team.

Referrals

Make a referral

Alternatively, you can contact the Adult Social Care helpdesk (Gloucestershire County Council) on 01452 426868.

Accessible Housing

Our Specialist Housing Occupational Therapist Neil Withnell provides specialist advice and expertise on housing, disability and relevant legal issues in partnership with colleagues at our Trust, NHS Gloucestershire ICB, district housing partners, clients and carers. As part of his role, Neil campaigns for targets in local plans for accessible housing and is on hand to explain this complex issue and provide the evidence base informing it.

Find out about Neil’s role as well as the support our Trust provides for people recovering from a mental illness on our Housing and Accommodation team page.

The role of reablement is to support people to lead independent lives in their own home, safely and appropriately, for as long as possible by enabling them to do things for themselves instead of relying on others to do things for them.

Typically, reablement support is given to people following an illness, injury or other sudden event which may have reduced their physical, emotional or psychological ability to manage their own lives.

Our reablement workers receive specialised training, and work in the area as part of our integrated community teams.

Reablement is delivered in partnership with the service user, as the reablement worker and the individual both have responsibilities in working towards recovery and the agreed goals.

Together, we support people to be in control of their choices and to maintain their independence safely and appropriately. We will also ensure we refer on for specialist care when it is needed.

When will I first see a reablement worker?

The Complex Care at Home Team provide personalised support and care to adults who are losing their independence and resilience due to multiple/complex needs. This support will include care co-ordination, clinical expertise, health coaching and information and advice to help people manage their conditions, enabling them to access on-going low level support in the community.

The teams operate in Cheltenham, Gloucester and the Forest of Dean.

Referral Criteria:

• Over 18 and registered with a GP within Gloucester, Cheltenham or the Forest of Dean
• Consented to referral (cognition considered)
• Rockwood score of 4-7
• 2 or more Long term conditions (including frailty)
• Becoming reliant on unplanned or Emergency care
• At risk of unplanned admission
• Has had unplanned admission in the last 6 months
• Has health and wellbeing goals/ambitions
• Would benefit from MDT approach to personalised care and support planning

Exclusions:

• People referred solely for therapy support of needs (Refer to ICT)
• People without 2 long term conditions
• People referred solely for nutritional support
• Complex mental health conditions
• Active substance misuse
• Referral solely for memory assessment or mental health assessment – Refer to Memory Assessment Service (MAS)
• People with no physical health conditions
• End of Life Care
•  

Contact us

Email:  ComplexCareAtHome@ghc.nhs.uk
Call: 0300 421 1389

The Trust’s approach to end of life care is based on ‘Six Ambitions for Palliative and End of Life Care – a national framework for local action 2015-2020’ which you can read in full by following this link.

Useful links

Ambitions for Palliative and End of Life Care
A national framework for local action

The Gold Standards Framework
Training in end of life care

Carers Gloucestershire
Support, advice and advocacy for carers

Marie Cure
Care and support through terminal illness

Winston’s Wish
The charity for bereaved children

Resources for Nutrition and Hydration at End of Life

End of life care for infants, children and young people with life-limiting conditions: planning and management (NICE Guidance)

End-of-life-nutrition (BDA)

Changes in the last hours and days – NHS

Hydration and nutrition Information for professionals from mariecure

Care of dying adults in the last days of life (NICE Guidance)

When a Hospice Patient Stops Eating or Drinking (VITAS Healthcare)

Basic Symptom Control Manual for Paediatric Palliative Care (Short Lives)

Tissue viability is concerned with skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration.

Pressure ulcers, also known as bed sores or pressure sores, are a type of injury that affects areas of the skin and underlying tissue.

Pressure ulcers are caused by poor circulation to tissues due to one or more of:

• Pressure – constant pressure between a surface and part of the body, usually over bony areas such as heels, hips, bottom
• Shear – when layers of skin are forced to slide over one another, for example when you slide down or are pulled up a bed or chair
• Friction – rubbing of the skin

Anyone can get a pressure ulcer, of any age young or old, but the people who are most at risk are the elderly and those in ill health. Our tissue viability team provides specialist advice, support, education and training in all aspects of tissue viability.

Contact us

Email:  tissueviability@ghc.nhs.uk
Call 0300 421 1407

Useful links

• More information on pressure sores can be found on the NHS website.
• Wound Care Alliance UK:  www.wcauk.org
• Tissue Viability:  www.tvs.org.uk/
• Pressure Sore campaign group:  www.your-turn.org.uk/
• European Pressure Ulcer Advisory Panel:  www.epuap.org/
• Wounds UK: www.wounds-uk.com

Non-Formulary Exception Form

The Complex Leg Wound Service (CLWS) works within clinic and community settings. This nurse led specialist service see people principally in community clinics, but can after discussion support patients resident in our hospital wards or in their own homes where specialist assessment cannot be achieved in a clinic setting.  Clinics are run from a number of sites:

• Cirencester Hospital
• George Moore Clinic in Bourton on the Water
• Lydney Hospital
• Milsom Street Clinic in Cheltenham
• Stroud Hospital

Complex leg wounds are those which have failed to heal, those which are large in size or where long term conditions, including vascular or arterial impairment may be a factor in wound healing.  Venous leg wounds are estimated to affect around 1 in 500 people in the UK, although they become much more common with age. It’s estimated around 1 in 50 people over the age of 80 has a leg wound.

The service aims to work with the patient to promote wound healing, utilising specialist vascular, orthopaedic and dermatology colleagues in the hospital as necessary and requesting venous scanning as part of assessment. They enable people to achieve self-management wherever possible and to provide education and supervision to health care professionals engaged in providing care for those living with leg wounds.

You can call the team on 0300 421 8755
Or email them at complexlegwounds@ghc.nhs.uk

Referrals must be sent on a referral form and can only be accepted if signed by a medical practitioner. The form can be found here.

The Lymphoedema team works within clinic and community settings. This nurse led specialist service see people in their own homes, in community clinics, on wards and in care homes. Clinics are run across the county and centrally from Southgate Moorings in Gloucester.

Lymphoedema is a chronic and permanent swelling which can affect any area of the body, most commonly affecting the limbs. It can occur at or soon after birth (primary) or as a result of surgery involving the lymph nodes (secondary). It results from poor drainage of the body’s lymphatic system. It affects over 100,000 people in the UK of all ages and genders.

The service aims to encourage individuals to achieve self-management wherever possible and to provide education and supervision to health care professionals engaged in providing care for those living with lymphoedema.

You can call the team on 0300 421 7030
Or email them at Lymphoedema@ghc.nhs.uk

Referrals must be sent on a referral form which can be found here

Call: 0300 421 8147

Telehealth is a specialist service for heart failure and respiratory patients. It uses an electronic monitoring device in the home to monitor a person’s vital signs, including blood pressure, weight and blood glucose. The patient may use the device daily, or more frequently, depending on their needs. The easy-to-use device asks a range of health and quality of life questions which the patient answers on a key pad or touch sensitive screen. Physiological data can also be recorded, such as:

• Blood pressure
• Weight
• Heart rate
• Oxygen levels

Once obtained, the data is transmitted using either the patient’s home phone connection (using encrypted messaging on a free-phone number) or via GPRS mobile phone connection to a central computer server.

The data is compared against pre-set parameters and any areas of concern are reviewed by a specialist nurse and action taken as required.

Using Telehealth, patients learn to manage their own condition, which often results in fewer visits to their home from clinicians and fewer visits to GPs.

Telehealth is not an emergency service and patients will still  need to contact GPs or emergency services if necessary. However, the number of hospital admissions is reduced and care can be managed, and trends analysed.

What is Telehealth?
Telehealth is the remote monitoring of a patient’s vital signs, health and well-being through monitoring equipment located in the patient’s home.

How does Telehealth work?
The monitor along with various peripherals, e.g. blood pressure monitor, is installed in a patient’s home. At a time agreed with the specialist nurse the patient will take their vital signs readings and answer symptomatic health questions.

What vital signs can be measured using Telehealth?
Vital signs include blood pressure, oxygen pulse oximetry, weight and heart rate.

Can anyone apply to join the specialist Telehealth programme?
No, currently specialist Telehealth is being used with patients already known to the Heart Failure and Respiratory services. Referrals are not taken from outside these services.

Does the service cost the patient?
No, the equipment is provided on loan from Gloucestershire Health and Care NHS Foundation Trust. Data is transferred on a free 0800 number. There is a small cost to the patient for electricity used by the equipment.

Is there a formal agreement between Gloucestershire Health and Care NHS Foundation Trust and the patient/carer?
At the time of installation a consent form is signed by the patient, acknowledging that the equipment is owned by Gloucestershire Health and Care NHS Foundation Trust and may be removed at any time.

How long will the equipment remain in the patient’s home?
The equipment will remain in the patient’s home for as long as it is deemed necessary by the clinician. However, it will be reviewed every 13 weeks and withdrawn on clinical or other grounds.

What are long term conditions?
Long-term conditions are defined as chronic conditions that require on-going management.

Does the patient need to have a broadband connection?
No, the equipment currently being used in Gloucestershire works on either an analogue landline telephone or through a GPRS system.

Useful links

Telecare Aware – a useful website with lots of information about what is currently going on in the world of telehealth and telecare.

Telehealth equipment manufacturers used by Gloucestershire Care Services NHS Trust:

THSL www.thsl.co.uk

Telecare supports people to maintain their independence and also promotes safety and reduced risk within the home. The Telecare service is commissioned by Gloucestershire Health and Care NHS Foundation Trust and provided by Gloucestershire County Council.

Find out more about Telecare here.

The Gloucestershire Wheelchair Assessment Service provides wheelchairs and wheelchair accessories to those with medium to high specialist needs and to those who will need the equipment for long term use of more than six months.

The Gloucestershire Wheelchair Services now has its own dedicated website – please follow this link (opens in new window)