Primary Care at Home (PCaH) teams have been launched by Bedfordshire Community Health Services (BCHS).
The teams have been formed as part of work to provide better, joined-up care for patients across Bedford Borough and Central Bedfordshire.
They will support primary care networks in the delivery of both planned and unplanned care for housebound patients who require support.
They help people with long-term conditions which can include diabetes or respiratory problems and also help people return to independent physical function, supporting those patients to remain at home who may otherwise have been admitted to hospital.
The newly-formed teams include BCHS services which previously operated independently.
District nurses, community matrons, occupational therapists (OTs), rehab support workers and care coordinators now work side-by-side to provide coordinated care.
They will accept referrals and allocate the appropriate professional from the team to undertake a holistic assessment.
The nominated team member will then draw up a care plan in partnership with the patient to ensure they receive the most appropriate care.
The teams provide daytime unplanned care support, which was previously delivered by the Rapid Intervention team (RIT).
A countywide night service will also support patients to remain in their own homes by delivering planned and unplanned care.
Three PCaH teams have been formed and are based in the north, mid and south of the county.
They work closely with all other social and health care providers to meet the needs of their patients, including involvement at GP Cluster MDT (Multi Disciplinary Team) meetings, led by GPs, to decide on patients’ needs.
“At its heart, this project is about giving patients a more joined-up, effective and responsive package of care,” said Ruth Bradley, Director of Nursing - Integrated Care.
The three teams went live on July 8, 2019.
They can be contacted through the BCHS Single Point of Access (SPoA) on Tel: (0345) 602 4064.