Integrated Community Teams
Our integrated community teams (ICTs) bring together community nurses, occupational therapists, physiotherapists, social workers and reablement workers to work as one team to serve a local area.
These teams work alongside GPs to provide care for people in their place of residence or in the community.
They also work with the ward teams based in our seven community hospitals across Gloucestershire, and with our countywide specialist services, voluntary organisations and other care providers to provide assessments, treatment and support for people within the community. We have teams based in Gloucester, Stroud, Cheltenham, north and south Cotswolds, Tewkesbury and the Forest of Dean.
Who we support
Our integrated community teams combine services provided by the NHS and Gloucestershire County Council.
We provide services to anyone who, for health reasons, cannot access hospital appointments or primary care services such as a visit to the GP.
You must be registered with a Gloucestershire GP in order to access our service.
The type and range of support provided by the teams is targeted to meet the individual needs of patients and their carers/family.
The support we provide
We provide services to:
- People needing short term support to recover from an illness or injury
- People who need support in living well with a long term health condition or disability
- People who have a terminal diagnosis and want to be supported to be at home for the end of their life.
Community nurses (sometimes known as district nurses) mainly visit people who are ill at home and are unable to get to services based at the doctor, hospital or other clinics. Our nurses may also see people in clinics or other settings to provide specific services, such as care for leg ulcers.
Community and district nurses specialise in:
- Nursing care and advice for people who are really unwell but can be looked after at home
- Nursing care and advice after an operation
- Palliative care and end of life care
- Care and advice to manage a long term health condition
- Wound care and advice
- Advice about continence problems
- Advice about healthy living
- Assessing people’s nursing needs
- Referring people where appropriate to other services
Although the community nursing service can provide nursing care 24 hours a day, we mainly visit patients in the daytime. Your doctor, the hospital or someone else looking after you may arrange for a nurse to come to your home.
Referrals for physiotherapy intervention in the patients home mainly come from the ward physiotherapist after surgery, or from your GP/consultant or other healthcare professional 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.
Our occupational therapists treat adults aged 18 years and over with physical and social problems in order to improve everyday functions and to support them to live independently and safely in their own home.
This may range from adapting household products so people can use them, to teaching those with problems different coping strategies, to helping service users participate in social activities.
Occupational therapists are problem solvers who empower people to take control of their lives
* Occupational therapy services in at Cheltenham General Hospital and Gloucestershire Royal Hospital are provided by Gloucestershire Hospitals NHS Foundation Trust.
Occupational therapists work as part of our integrated community teams. These bring together occupational therapists, physiotherapists, social workers, reablement workers and community nurses to work as one team to serve a local area.
The role of GPs is pivotal in this, together with our skilled teams based in our seven community hospitals across Gloucestershire.
Our integrated community teams also work closely with our countywide specialist services, voluntary services and other care providers to provide assessments, treatment and support for people within the community.
Where may I be seen?
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 ensure a co-ordinated approach to your care.
If you are in a community hospital, you will be seen by one of our occupational therapists based there.
How can occupational therapy help?
We aim to:
- Prevent emergency hospital admissions and readmissions
- Support people to live at home
- Prevent avoidable harm to older people such as falls
- Improve access to the service by reducing waiting lists and increasing responsiveness.
- To encourage and facilitate independence in daily living activities
- To place users and carers at the centre of our activities and provide a client centred service
- To work in partnership with users and carers, the voluntary sector, other agencies and other sections and groups to achieve the best possible service
- To assist in prevention of admission or re-admission to hospital, admission to long-term care and to enable early discharge from hospital
We will do this by:
- Providing individual assessments of adults, working with the assessment of carers needs, to help maximise independence wherever possible
- Providing specialist equipment to help with daily tasks, and instruction on how to use equipment provided
- Managing equipment on loan including storage and maintenance, delivery/collection and fitting
- Liaising with staff from statutory and voluntary sectors to facilitate Hospital discharge
- Providing advice and information relating to disability issues to service users, carers and professionals
- Carrying out risk assessments in line with Moving and Handling Regulations and providing advice, equipment and instruction as appropriate
Adult social care only
Following an assessment – and potentially a period of reablement – we help to identify and help to provide both major and minor adaptations to properties (this includes making recommendations to environmental services for Disabled Facilities Grants (DFGs) and Home Repair Assistance Grants and design in new and refurbished accommodation for disabled service users.
You may be in an interim bed, perhaps having been discharged from Cheltenham General or Gloucestershire Royal Hospital 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.
How do I see an occupational therapist?
Referrals come from a range of sources including self-referrals, GPs, healthcare professionals and social workers. If you are already receiving a service from a member of your local community team, they will be able to make the referral on your behalf.
If you are in one of our seven community hospitals, you may also be referred for occupational therapy from one of the hospital team.
Alternatively, you can contact the Adult Social Care helpdesk (Gloucestershire County Council) on 01452 426868.
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 first contact might be any member of the integrated community team – for example, community nurse or physiotherapist – depending on your needs and the support that is required.
How often will a reablement worker visit?
Visits will be planned with you and might initially be several times a day, reducing over time as you begin to recover your independence.
How do I contact my reablement worker?
You can also contact the Adult Social Care Helpdesk, which is run by Gloucestershire County Council and advises on a range of issues. The Helpdesk is open 8am – 5pm, Monday – Friday and can be contacted on 01452 426868.
When you are visited for the first time you will be provided with the name and contact details of your local integrated community team who will coordinate your care.
If you are a health professional with an enquiry about reablement services, please contact the Single Point of Clinical Access (SPCA) for information
How will my family/carers be involved?
Complex care at home
The Complex Care at Home (CC@H) service is a preventative, proactive model of care provision that aims to support people at home using a Case Management approach. The service runs in Cheltenham and Gloucester, weekdays from 8am to 6pm.
The team consists of Community Matrons / Case Managers, Dementia Matrons with a RMN qualification, Physiotherapists, Occupational Therapists, a Dietitian, Social Care Practitioners and Wellbeing Coordinators.
The CC@H service accepts referrals from GPs, Integrated Community Teams, Rapid Response, Specialist Services, the Enhanced Discharge Service, the Integrated Assessment Team and its voluntary partners.
Aims of the service
The CC@H service aims to proactively manage patients with complex health needs, in the community, who may previously have been high users of primary care and/or urgent care services. Using a case managed proactive approach to care, there will be a reduction in unplanned admissions to the acute services and/or a delay in escalation of their health and social care needs.
- Proactive management of patients in the community who may have been previously high users of primary and urgent care services
- Patients will be seen within 10 working days of referral being received
- Use of a case managed coordinated approach to care
- Person centred approach using the tool “My Life, My Plan”(see appendix a)
- Support the person to improve their health and wellbeing by developing a patient centred partnership
- Put the person and their family/carer at the centre of their treatment/care plans
- Improve patient and carer experience
- Reduction or delay in escalation to a care home placement, or nursing home bed
- Better use of assistive technology, such as Telecare and Telehealth to support more patients at home
Referrals are not accepted for people who:
- Are under 18 years of age
- Have complex Mental Health (MH) issues affecting their ability to engage with services
- Have complex MH issues requiring specialist mental health treatment or patients who are under the care of the Crisis Team
- Are misusing alcohol or drugs to the extent that they are substance dependent
- Very frail, with a frailty score of 8-9 already under the care of the Community Frailty Matrons
- Entering or believed to be at end of life stage
- Require emergency or urgent medical or social intervention/assessment
- Are acutely unwell
End of life care
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.
Ambitions for Palliative and End of Life Care
A national framework for local action
The Gold Standards Framework
Training in end of life care
Support, advice and advocacy for carers
Care and support through terminal illness
The charity for bereaved children
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.
Call 0300 421 1407
- 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
If you are thinking of using a wound management product which is not on the Gloucestershire formulary, please follow the link below for an exception reporting submission:
Complex leg wound service
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 firstname.lastname@example.org
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
- 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.
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:
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.
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