Exciting future for NHS team which is helping keep people stay well at home
An NHS team which is helping people in York age well and stay out of hospital, is expanding.
The York Integrated Community Team (YICT) will be joining Nimbuscare this month, having previously been part of Priory Medical Group.
The team, which coordinates care to around 4,000 York patients (around 2% of York’s population), works in partnership with health, care and voluntary organisations across the city, as well as our 10 City centre GP member practices.
YICT works with older people and those who have been identified as struggling with long term health issues, making sure they get the right care and support they need to continue to live independent lives. The team has been responsible for the development of many new initiatives across the city to meet unmet health and social needs of patients.
The team is a central point of contact between patients and the health and social care services. It includes Frailty Nurses, GPs with a specialist interest in Frailty, Care Navigators, Occupational Therapists, Physiotherapists, Social Prescribers, Dieticians, Healthcare Supports (Healthcare Assistants), Nursing Associates, Therapy Assistants and Paramedics.
The aim is to reduce avoidable hospital admissions, support patients to leave hospital earlier and, crucially, help patients to remain independent at home for longer.
New initiatives from the team include the ‘In-reach Service’ which helps patients to be discharged from hospital quicker, by giving them the support they need at home.
YICT also runs the York Frailty Assessment clinic which is a holistic assessment clinic for older people, allowing them to discuss their health and social concerns with a GP/Consultant-led multidisciplinary team.
A two-hour urgent community response team is another service which is run in partnership with York and Scarborough Hospitals NHS Foundation Trust. This is an urgent response to people who are having a health crisis at home. The aim of this service is to prevent hospital admission.
Maddy Ruff, Nimbuscare’s Chief Executive said: “We would like to welcome this fantastic team which has grown exponentially in the last two years. They provide help and support to patients across the City, helping them navigate the system and get the care they need, when they need it. I hope this move to Nimbuscare will strengthen this service and help the team build on the excellent work they have done since being set up by Priory Group in 2014.”
The team is organised into neighbourhoods and around Primary Care Networks (GP practices working in teams) as much as possible, to meet individual and population health needs. It links closely with Primary Care, voluntary sector, hospital, community, mental health, and other services.
Dr Emma Olandj, GP, Medical Director of YICT and Clinical Director for Adult Community Services, said: “Here in York we have great relationships, fresh perspectives and true collaboration which helps us improve patient care. The team currently provides around 9,000 visits to patients in their own homes each year. A large part of our work is about identifying their needs early, so that we can be prepared and avoid crisis situations whenever possible.
“This move will help us move further towards true integrated care with hospital, community, voluntary sector and social care teams; working together with primary care clinicians to offer joined up frailty services for our patients and keep people safe in their own homes."
How the team benefits patients:
- Making sure patients have a named nurse and have access to call the team five days a week, if needed. (The service does run for seven days a week).
- Avoiding hospital admissions by picking up on patient physical, mental or social health concerns earlier and responding to individual needs.
- Providing a two-hour Urgent Community Response alongside the York and Scarborough Hospitals NHS Foundation Trust Community team to prevent admissions to hospital in crisis situations.
- Liaising with patients’ own GP to support patients at home, when needed.
- Providing routine review of all patients on its register to check for signs of increasing frailty and to offer referrals and access to services, as needed on a personal basis.
- Supporting with discharge from hospital and supporting people at home, so they can get out of hospital quicker.
- Working with community teams to help patients who are well enough medically to leave hospital, but their discharge has been delayed.
- Reviewing and supporting patients, once they come home to reduce the chance of readmission to hospital.