Service Detail

Telephone number: 0300 200 0011 

Referral Criteria: Registered with a GP in Coventry; Self Referral or health professional
 

Our Community Nursing team works jointly with a patients' GP and other health care professionals to deliver care and treatment in a patients' home, or residential care home, 24 hours a day, seven days a week.

The main areas the team work in are:

·         Palliative and end of life care;

·         Wound care and pressure ulcers;

·         Long term conditions e.g. diabetes;

·         Continence care.

The team delivers care and treatment to patients in their own home, or residential care homes. The team has case management skills, clinical supervision skills and an extended knowledge of long-term conditions.
The service plays a vital role in keeping hospital admissions and re-admissions to a minimum, ensuring patients can return to their own homes as soon as possible.

The Community Nursing team includes: a Team Manager,  Community Nursing Sisters, Community Staff Nurses,  Health Care Assistants and Assistant Practitioners.

The service has links with GPs and social workers, as well as the following services: Community Matrons, Tissue Viability, Continence, Podiatry, Community Rehabilitation, Occupational therapy, Physiotherapy,  Mental Health, Psychology, Specialist Palliative Care and Speech and Language.

Referral criteria:
Referrals are through the Central Booking Service and will be received from health care professionals for patients who are:

• registered with a Coventry GP;
• aged 18 years or over;
• housebound due to health conditions;
• housebound due to transport requirements, where a delay in treatment would result in a deterioration of health care status; 
• have a specific nursing need;
• have a clinical need that requires the treatment to be delivered within their home environment;
• require non-urgent nursing care, intervention in their own home, or appropriate community based setting;
• diagnosed with a terminal illness and/or are in the terminal phase of their illness and require a community nursing assessment;

The Central Booking Service is also a self-referral service: 0300 200 0011
(8am - 8pm, seven days a week)

 

Community Matrons 

Coventry’s Community Matrons are advanced practitioners and independent nurse prescribers who case-manage patients with complex long term conditions. Working closely with GPs, consultants, community nurses, specialist nurses, therapists, social services and voluntary agencies they aim to reduce the incidence of avoidable hospital admissions through a variety of interventions and support.

Community Matrons work with individuals who are at high risk of hospital admission, to help them to manage their own conditions more effectively and improve their quality of life by monitoring and co-ordinating care that is needed to keep them out of crisis. The level of care that is provided will depend on a person’s individual needs.

Community Matrons provide a 7day/week service and spend 50%of their time seeing patients and 50% of their time providing clinical leadership to the community nursing teams. They support the frailty pathway at UHCW to promote early discharge of patients. They also work in the Integrated Neighbourhood Teams which provide multi-disciplinary intervention to patients who may require a number of different health and social care services  to support them in the community.

Referral criteria:

1. Urgent referrals are accepted from GPs to prevent hospital admission and from UHCW to facilitate hospital discharge.

2. Routine referrals are accepted from GPs, other health professionals and hospital staff if they meet the following criteria:

They have been diagnosed with two or more long term conditions,

which are unstable/complex and which have a high impact on their

daily life or activities;

AND

They have had two or more avoidable hospital admissions or ED visits within the last 12 months, or significantly increased contact with their GP or unscheduled care services.