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Adults' service descriptions

Urgent community response and hospital at home

Also known as and includes Acute Response Team, Rapid Response, Frailty Home Treatment, and community Virtual Wards

These are based in the community and are provided to people in their own home or a care home with the aim of avoiding hospital admissions. Care can be accessed from a multi-disciplinary team within two hours. For some patients, hospital-level care is provided for a limited period using digital technology to monitor things like blood oxygen, blood pressure, and temperature)


Integrated discharge teams

Also known as IDT, and Transfer of Care Hubs

These multidisciplinary teams help people to get home from hospital as soon as possible with the right care once their medical conditions are stable. They proactively manage patient’s pathway to reduce their length of stay.


Intermediate care (short term care)

Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent to hospital. These services are made up of physiotherapists, occupational therapists and rehabilitation assistants whose advanced skills provide comprehensive rehabilitation to patients with long term conditions. It includes assisting people to compensate for difficulties that cannot be reversed and promotes coping strategies to overcome any loss in previous ability. The therapists not only consider the physical and cognitive needs of an individual but the social and psychological factors as well. This includes:


Bed-based intermediate care

Also known as Community Beds

These are provided in an acute hospital, community hospital, residential care home, nursing home, standalone intermediate care facility, independent sector facility, local authority facility or other bed-based settings.


Reablement services at Home

Also known as Home First, Discharge to Assess, Enablement

These are based in the community and provide assessment and interventions to people in their own home or a care home. These services aim to help people recover skills and confidence to live at home and maximise their independence


Musculoskeletal (MSK) physiotherapy services and community orthopaedics

Includes Hand Therapy, MSK and orthopaedic triage services

MSK physiotherapy is the treatment of a wide range of injuries, disorders and diseases that affect joints, muscles, ligaments and tendons. Sports injuries, joint pain, complex pain conditions such as arthritis and problems after some surgical procedures are examples of issues that musculoskeletal physiotherapy can help treat.

Community orthopaedics services use non-surgical approaches to treat musculoskeletal issues assessing and diagnose patients and involving them fully in a care plan created for them. We refer patients to surgery or to other services when appropriate, and treat patients with long-standing musculoskeletal problems that have not been resolved through GP management and physiotherapy.


Podiatry

These services maintain mobility, alleviate pain and reduce the risk of infection, ulceration and amputation in patients with high-risk medical complaints or complex foot problems. We can help people suffering with, nail problems, such as in-growing nails and nail deformities, corns and callus. We also help with foot and toe deformities, such as bunions and hammer toes, biomechanical problems and heel pain.


Speech and Language Therapy Services (SALT)

These services provide support and advice to adults with acquired communication and/or swallowing disorders. This includes all aspects of communication, including speech, language and voice.


Continence care/ Continence management services

Manages incontinence by providing written information, education, treatment, management and support to patients, their carers and to trained healthcare staff responsible for their care


Community Respiratory

Includes Pulmonary Rehabilitation

Provides respiratory assessments and treatments to patients with lung conditions, including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), bronchiectasis and asthma.


Diabetes

Provides education, support and treatment to empower people living with diabetes to live independent, healthy lives. Specialist nurses, dietitians and educators work closely with other healthcare professionals to support people living with diabetes, their carers and their families.


Nutrition and dietetics

Diagnoses and treats dietary and nutritional problems at an individual and wider public-health level. The service works with healthy and sick people in a variety of settings, including the food industry, workplace, and education settings. It also works with people with mental health conditions, learning disabilities in the community and sometimes in-reach into hospitals.


Community nursing

Includes specialist and complex nursing services, and Parkinsons

These services delivers a wide variety of nursing care from wound therapy to palliative care and nurse prescribing.

Complex care nursing provides nursing care for housebound patients (people who cannot leave their home), aged 18 and older, in the community, seven days-a-week. The service delivers care to people with complex and long-term conditions, as well as supporting and giving advice to families and carers, working closely with other healthcare professionals, social services and voluntary agencies.


Tissue viability

These services provides support and advice on all aspects of complex wounds, pressure damage and leg ulcer management.


Lymphoedema

Provides education, advice and support to manage the condition, completing assessments and helping people with ongoing management.


Health and social care coordinators and health trainers

Includes MDT coordinators, health trainers, and expert patient programmes

These services provide support to adults with long-term conditions and helps improve their overall health and wellbeing. Coordinators help patients engage with wider health and social care sectors and improve self-management of conditions, reducing unnecessary hospital admissions.


Community Cardiology

Includes Arrythmia, Heart Failure, Cardiac rehabilitation

These teams provide non-urgent cardiology diagnostics such as 24-hour blood pressure monitoring, five-day cardiac event recorders, and twelve lead ECGs to the community, and support to patients with Arrhythmia by assisting with the diagnosis and treatment of people with abnormal heart rhythms, such as atrial fibrillation, ventricular tachycardia, supraventricular tachycardia and heart blocks. Cardiac rehabilitation offers short-term exercise programmes to support with lifestyle changes and provides physical, social and psychological rehabilitation.


Anti-coagulation service

Provides a one stop shop monitoring service for people who require INR/warfarin monitoring for more than one year.


Falls and postural stability services

Teams of physiotherapists, occupational therapists and rehabilitation assistants who provide assessments to patients with a history of falls or who are at risk of falls.


End of Life and Palliative Care

These services support those helps those nearing the end of their life to live as well as possible until they die. The service provides nursing care and therapy, in partnership with your GP, to help support you, your family and carers during the last phase of your life. This includes support at home, in care homes, and sometimes in a hospice setting.


Night sitting services

A night sitting service is used to provide a live-in carer or a family carer with a break from their care duties during the night.


Chronic pain

Specialist teams of nurses, doctors, psychologists, physiotherapists, advanced pain practitioners and supportive therapists that help people who suffer from persistent pain develop ways to self-manage their pain.


Learning disability service

Provides specialist health advice to people with learning disabilities, their carers, families and the wider health and social care community.


Adult autism and ADHD service

Provides assessment and support to autistic people and people with attention deficit hyperactivity disorder (ADHD).


Communication and Assistive Technology (CAT) Service

Supports patients with communications aid equipment in their own home. Its work includes all forms of communications (other than speech) that are used to express thoughts, needs, wants and ideas and equipment that helps people with tasks they would otherwise be unable to do


Community Stroke services

Specialist nurses and therapist support stroke survivors in the community at home, and sometimes in a in a bedded setting

Urgent community response and hospital at home

Also known as and includes Acute Response Team, Rapid Response, Frailty Home Treatment, and community Virtual Wards

These are based in the community and are provided to people in their own home or a care home with the aim of avoiding hospital admissions. Care can be accessed from a multi-disciplinary team within two hours. For some patients, hospital-level care is provided for a limited period using digital technology to monitor things like blood oxygen, blood pressure, and temperature)


Integrated discharge teams

Also known as IDT, and Transfer of Care Hubs

These multidisciplinary teams help people to get home from hospital as soon as possible with the right care once their medical conditions are stable. They proactively manage patient’s pathway to reduce their length of stay.


Intermediate care (short term care)

Intermediate care services are provided to patients, usually older people, after leaving hospital or when they are at risk of being sent to hospital. These services are made up of physiotherapists, occupational therapists and rehabilitation assistants whose advanced skills provide comprehensive rehabilitation to patients with long term conditions. It includes assisting people to compensate for difficulties that cannot be reversed and promotes coping strategies to overcome any loss in previous ability. The therapists not only consider the physical and cognitive needs of an individual but the social and psychological factors as well. This includes:


Bed-based intermediate care

Also known as Community Beds

These are provided in an acute hospital, community hospital, residential care home, nursing home, standalone intermediate care facility, independent sector facility, local authority facility or other bed-based settings.


Reablement services at Home

Also known as Home First, Discharge to Assess, Enablement

These are based in the community and provide assessment and interventions to people in their own home or a care home. These services aim to help people recover skills and confidence to live at home and maximise their independence


Musculoskeletal (MSK) physiotherapy services and community orthopaedics

Includes Hand Therapy, MSK and orthopaedic triage services

MSK physiotherapy is the treatment of a wide range of injuries, disorders and diseases that affect joints, muscles, ligaments and tendons. Sports injuries, joint pain, complex pain conditions such as arthritis and problems after some surgical procedures are examples of issues that musculoskeletal physiotherapy can help treat.

Community orthopaedics services use non-surgical approaches to treat musculoskeletal issues assessing and diagnose patients and involving them fully in a care plan created for them. We refer patients to surgery or to other services when appropriate, and treat patients with long-standing musculoskeletal problems that have not been resolved through GP management and physiotherapy.


Podiatry

These services maintain mobility, alleviate pain and reduce the risk of infection, ulceration and amputation in patients with high-risk medical complaints or complex foot problems. We can help people suffering with, nail problems, such as in-growing nails and nail deformities, corns and callus. We also help with foot and toe deformities, such as bunions and hammer toes, biomechanical problems and heel pain.


Speech and Language Therapy Services (SALT)

These services provide support and advice to adults with acquired communication and/or swallowing disorders. This includes all aspects of communication, including speech, language and voice.


Continence care/ Continence management services

Manages incontinence by providing written information, education, treatment, management and support to patients, their carers and to trained healthcare staff responsible for their care


Community Respiratory

Includes Pulmonary Rehabilitation

Provides respiratory assessments and treatments to patients with lung conditions, including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), bronchiectasis and asthma.


Diabetes

Provides education, support and treatment to empower people living with diabetes to live independent, healthy lives. Specialist nurses, dietitians and educators work closely with other healthcare professionals to support people living with diabetes, their carers and their families.


Nutrition and dietetics

Diagnoses and treats dietary and nutritional problems at an individual and wider public-health level. The service works with healthy and sick people in a variety of settings, including the food industry, workplace, and education settings. It also works with people with mental health conditions, learning disabilities in the community and sometimes in-reach into hospitals.


Community nursing

Includes specialist and complex nursing services, and Parkinsons

These services delivers a wide variety of nursing care from wound therapy to palliative care and nurse prescribing.

Complex care nursing provides nursing care for housebound patients (people who cannot leave their home), aged 18 and older, in the community, seven days-a-week. The service delivers care to people with complex and long-term conditions, as well as supporting and giving advice to families and carers, working closely with other healthcare professionals, social services and voluntary agencies.


Tissue viability

These services provides support and advice on all aspects of complex wounds, pressure damage and leg ulcer management.


Lymphoedema

Provides education, advice and support to manage the condition, completing assessments and helping people with ongoing management.


Health and social care coordinators and health trainers

Includes MDT coordinators, health trainers, and expert patient programmes

These services provide support to adults with long-term conditions and helps improve their overall health and wellbeing. Coordinators help patients engage with wider health and social care sectors and improve self-management of conditions, reducing unnecessary hospital admissions.


Community Cardiology

Includes Arrythmia, Heart Failure, Cardiac rehabilitation

These teams provide non-urgent cardiology diagnostics such as 24-hour blood pressure monitoring, five-day cardiac event recorders, and twelve lead ECGs to the community, and support to patients with Arrhythmia by assisting with the diagnosis and treatment of people with abnormal heart rhythms, such as atrial fibrillation, ventricular tachycardia, supraventricular tachycardia and heart blocks. Cardiac rehabilitation offers short-term exercise programmes to support with lifestyle changes and provides physical, social and psychological rehabilitation.


Anti-coagulation service

Provides a one stop shop monitoring service for people who require INR/warfarin monitoring for more than one year.


Falls and postural stability services

Teams of physiotherapists, occupational therapists and rehabilitation assistants who provide assessments to patients with a history of falls or who are at risk of falls.


End of Life and Palliative Care

These services support those helps those nearing the end of their life to live as well as possible until they die. The service provides nursing care and therapy, in partnership with your GP, to help support you, your family and carers during the last phase of your life. This includes support at home, in care homes, and sometimes in a hospice setting.


Night sitting services

A night sitting service is used to provide a live-in carer or a family carer with a break from their care duties during the night.


Chronic pain

Specialist teams of nurses, doctors, psychologists, physiotherapists, advanced pain practitioners and supportive therapists that help people who suffer from persistent pain develop ways to self-manage their pain.


Learning disability service

Provides specialist health advice to people with learning disabilities, their carers, families and the wider health and social care community.


Adult autism and ADHD service

Provides assessment and support to autistic people and people with attention deficit hyperactivity disorder (ADHD).


Communication and Assistive Technology (CAT) Service

Supports patients with communications aid equipment in their own home. Its work includes all forms of communications (other than speech) that are used to express thoughts, needs, wants and ideas and equipment that helps people with tasks they would otherwise be unable to do


Community Stroke services

Specialist nurses and therapist support stroke survivors in the community at home, and sometimes in a in a bedded setting