This service sees patients who are housebound and require nursing help such as wound dressings, continence assessments and also offers support for people who require end of life care. District Nurses visit patients following discharge from hospital and help to support people to avoid a hospital admission.
The service also offers therapy services (such as physiotherapy and occupational therapy) that can improve people’s mobility and functioning – including assessing people’s needs for equipment to support living at home.
The services work together to try to make sure that the right professional sees the patient and that if a person has any needs then the team can work to improve that person’s life.
Single Point of Referral
Single Point of Referral provides one contact number for all new referrals and will continue to provide systematic access to community nursing services - this is a Healthcare Professional Line only.
Enhanced Care Team (Telford and Wrekin area)
A case manager’s role is to deliver intensive management to people with Long term conditions over a defined period of time. Case managers act as key workers with responsibility for co-ordinating the decisions about care and service provision for patients in all health settings. Their aim is to support and educate patients and families to avoid preventable admissions or to facilitate early discharge.
This service is available from 8.00 am- 10.00 pm and consists of Nurses, Support Workers and a Social Worker who specialise in physical and mental health problems. They provide care in the community for people in crisis to prevent hospital admissions and can arrange admittance to the intermediate care beds, continuing the Integrated Primary Care Team role between 6.00pm - 10.00pm
Responsible for obtaining blood samples within the patients home and residential environment for those people who are housebound.
Hours of operation: Monday to Friday, 8.00am - 2.30pm
Advance Nurse Practitioner Urgent Care
Provide high level physical assessment, diagnosis and treatment for acute illness or exacerbation of chronic illness. They aim to avoid unnecessary hospital admission and facilitate early discharge within MAU and A/E. They are independent prescribers and have under gone further training in physical assessment and diagnosis. Their role also supports education for nurses and other healthcare professionals within the Community Health Services.
Referrals can be made once a diagnosis of dementia has been made by the memory service. The role is to support carers in managing the care of a person with dementia.
Admiral Nurses are specialist mental health nurses who aim to:
- Improve family carers wellbeing and quality of life.
- Enhance family carers adjustment and coping with the carers role.
- Improve the wellbeing and the quality of life of the person with dementia.
- Enhance the person’s ability to adjust and cope with the dementia.
- Enhance colleague’s knowledge and experience of working with families/carers and people with dementia
Nurse Consultant Primary Care
The Nurse Consultant is responsible for:
- providing clinical leadership to all community nursing teams;
- providing clinical leadership for developing the Long Term Conditions and Urgent Care Agenda;
- managing a case load of patients with complex health and social care needs;
- development of services to avoid hospital admission and provide care closer to home.
The Respiratory team are specialist nurses that care for patients with Chronic Obstructive Pulmonary disease or COPD, they support patients in their own homes and also support patients to be discharged from hospital as soon as possible.
Integrated Primary Care Team (Telford and Wrekin area)
The IPCT consists of:
- Team Leaders
- Community Nurses Older Peoples Champions
- Health Care Assistants
The Aim of the Integrated Primary Care Team (IPCT) is to provide nursing expertise and knowledge to meet the needs of the people of Telford and Wrekin who require care within their own homes. The ultimate aim of this care is to enable maximum independence, enable speedy recovery and avoid unnecessary hospital admission.
Community Nurses work from 8.30am to 6.00pm, 7 days a week.
They are responsible for assessing, planning and delivering care to patients in their own homes to help support them to remain at home wherever possible or to facilitate their safe discharge from hospital including patients who are most vulnerable within the community and not engaging or accessing services available to them. They link closely with the case manager team to provide on going monitoring and support for patients with complex needs.
To make a referral to any of these services please contact you registered General Practitioner