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Reactive Care within Primary Care Networks

We have four reactive care teams working across Great Yarmouth and Waveney. These are split into the four Primary Care Networks:

Lowestoft
South Waveney
Gorleston
Great Yarmouth and the Northern Villages

The aim of these teams is to care for patients at home, avoiding the need to admit them to hospital wherever possible.

Evidence shows people recover better in the comfort and familiar surroundings of their own homes.

The teams are made up of community nurses, occupational therapists, physiotherapists, assistant practitioners/assessors, rehabilitation support workers and social workers. The integration of health and social care professionals means we can offer a really ‘joined up’ service and avoids the need for patients to receive multiple visits and repeat the same information to several different clinicians.

 

The teams operate from 8am to 10pm. They work alongside a patient’s own GP within the Primary Care Network to provide intensive, short-term care (up to two weeks). Patients in crisis can be assessed within two hours or 24 hours of referral depending on urgency and, as well as carrying out nursing and re-ablement, the team can organise equipment should the patient need it on a short term loan. They also offer advice and support to family and carers.

Our clinicians use a bespoke mobile working system which delivers up-to-date patient records, including X-ray reports, test results and prescription information, at their fingertips in patients’ homes.

 

The reactive care teams also have exclusive admission rights to a number of beds across Great Yarmouth and Waveney care homes, should a patient require round the clock or more intensive nursing care. In these cases the team monitors the patient’s care plans and provides support to the nursing home including advice on specialist therapy, mobilisation of patients and equipment.

 

REFERRALS

When a case is referred to the reactive element of the Primary Care Network, a triage team made up of health and social care professionals allocates an appropriate professional to provide the initial assessment. They develop and agree with the patient an individual care plan to give them the best chance of recovery, independence and wellbeing at home, ensuring that patients and their family or carers are fully included in the care planning process. The team then oversees the implementation of these plans and undertakes regular reviews to ensure that patients are progressing towards their optimum level of independence and health.

Referral is via a GP or health professional. Once one of our triage team members have had direct contact with the referrer a triage template is completed to identify if the patient is suitable for care at home, in beds with care or intermediate care beds. If the patient is not suitable for this service, advice is given on where support can be found and any steps to ensure the right care for the individual is recieved will be taken by the team. 

 

CONTACT

East Coast Community Access: 01493 809977

RESOURCES
Homeshield Leaflet Out of Hospital Leaflet
 
USEFUL LINKS

Home Shield Norfolk is a cross-agency referral service for professionals who work with vulnerable people and their carers.

Suffolk County Council Adult Community Services

Suffolk Care Line provides assistance and support to older, disabled and vulnerable persons requiring assistance and support to remain in their own homes.

Norfolk Social Services

Age UK provides a home visiting service to advise and help with benefit claims.