Nursing care at home

Who are we?

Inter Disciplinary Teams comprise community nurses, occupational therapists and physiotherapists who work together to deliver community health services to patients in their own homes.

The teams deliver urgent and planned care to patients helping to prevent avoidable admissions to a main hospital and to promote a healthy lifestyle as well as to maximise independence at home.

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Teams also work closely with partner agencies to deliver end of life (palliative) care to patients and their families, supporting people to die at home if this is their preferred choice, and with other specialist services in the community, such as specialist nurses, adult health assessment teams through the Diagnostics, Assessment and Access to Rehabilitation and Treatment (DAART) service, wheelchair services, community equipment services and the local hospice.

Nurses or therapists that you may see may also refer you to other members of the multidisciplinary team if you need more specialist advice and support.

Community Matron Service

Community matrons offer intensive case management for patients with many long term health conditions or patients who are regularly admitted to hospital.

Matrons work with patients and their family/carers to manage long term health conditions and plan for any changes of their conditions with the aim of keeping the patient out of hospital where appropriate.

Patients under the care of a community matron will have access to multidisciplinary assessment (assessment by more than one health specialist), treatment and care plans to support the patient and their family/carer to manage the long term conditions more effectively.
The nurse that sees a patient may refer them on to other members of the multidisciplinary team if needed, for specialist advice and support.

The Community Matron Service provides a range of services for patients with a range of long-term health conditions. These include:

  • multidisciplinary and medical assessment
  • intensive case management
  • intravenous (IV) drug administration
  • medicines management specialist care
  • specialist care and treatment planning

The people we see

The care provided by the Shropshire Community Health NHS Trust's interdisciplinary teams is for adults (over 18 year olds) living in Shropshire, Telford and Wrekin who are unable to travel to access specific health care services from their GP or other NHS health care providers.

New patients

There is an open referral process, this means that patients that need nursing care at home can be referred into the service by a GP or other relevant health care professional.

Services we do not offer

We are not able to offer nursing and therapy for patients who are able to travel to a clinic appointment for assessment or treatment.

Frequently asked questions

If a patient can travel to a clinic appointment, can they still access your service at home

No, they would be expected to attend a clinic or GP surgery. Help may be available with transport through Patient First on 01743 465565 or Dial-a-Ride on 01743 450350 but patients may have to contribute towards the cost of the journey.

Will you deliver services to patients over the long term?

This service doesn't provide long term care to patients, instead it provides intensive case management in the short to medium term.

 

Special Educational Needs and Disability (SEND) and our "Local Offer"

What is the Local Offer?

The local offer provides information for children and young people with special educational needs (SEND) and their parents or carers in a single place. You can find out more about information about this on our SEND reforms and Local Offers page.

Service Description

The Shropshire Inter Disciplinary Team (IDT) provides therapy and nursing in the patient’s home with the aim of preventing admission, supporting early discharge from hospital and promoting maximum independence. Team members include occupational therapists, nurses, physiotherapists, health care assistants, rehabilitation technicians, phlebotomists, community mental health nurses (CMHN for Shrewsbury and north-east Shropshire only, primarily for over 65s).

What do you provide to children and young people with an additional need and or disability 0-25yrs?

We provide services as above to adults age 18 or over, we provide general nursing and therapy services to support specialist services.

Do you provide support for parents and carers?

Yes, as part of the patient’s care or treatment programme.

Who can use our service? Age? Disability?

Patients age 18 or over requiring therapy and nursing in the home. There is no restriction on upper age limit or type of disability.

How to access our service (inc. referral routes)

Referrals - Who to contact?

North West (Oswestry)
To make a Referral call the triage line on 01691 663609

North East (Whitchurch)
To make a Referral call the triage line on 01630 650734

Central (Shrewsbury)
For patients registered with the following GP surgeries call the triage line on 01743 277709:

  • Riverside Medical Practice
  • Severn Fields Medical Practice
  • Marden Medical Practice
  • Claremont Medical Practice
  • Belvidere Medical Practice
  • Whitehall Medical Practice

For patients registered with the following GP surgeries call single point of referral at Halesfield on 0333 3584584

  • Pontesbury Medical Practice
  • Worthen Medical Practice
  • Westbury Medical Practice
  • The Beeches Medical Practice
  • Radbrook Green Medical Practice
  • Marysville Medical Practice
  • South Hermitage Medical Practice
  • Mytton Oak Medical Practice

Telford
To make a referral call the single point of referral at Halesfield on 0333 3584584

South East (Bridgnorth)
To make a referral call the single point of referral at Halesfield on 01746 711960

South West (Ludlow)
To make a Referral call the triage line on 01588 676323

When and where is our service available?

Interdisciplinary teams are based across shropshire in the North-West, North-East, Shrewsbury, Telford, South-West and South-East of the county. Standard service delivery across the county.

Services are delivered in the patient’s own home or usual place of residence and is available 7 days a week, 52 weeks per year; 08:00 – 18:00.

How can families contact the service?

Patient satisfaction surveys are conducted on an annual basis. We have a translation service available. Advice and support with communication is available from specialist services eg Learning disability nurses, speech and language specialist, if required.

Care and treatment plans are agreed jointly with the patient/carer.

Telephone the single point of referral on 0333 3584584 and basic advice can be given immediately, or a call back with a clinician can be arranged.

How we communicate with service users and how you are involved in decision making/planning

Patient satisfaction surveys are conducted on an annual basis. We have a translation service available. Advice and support with communication is available from specialist services e.g. Learning disability nurses, speech and language specialist, if required.

Care and treatment plans are agreed jointly with the patient/carer.

What training are the staff supporting children and young people with SEND had or are having?

Support from specialist services is sought when appropriate.

For external agencies: is the service free or charged?

Free as part of NHS

Is the service accredited? If so, by whom?

Care Quality Commission

How can families complain if they are not happy with the service?

All complaints are handled by our Patient Advice and Liaison Service (PALS) and Complaints teams.

 

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