Who we are
The Collaborative Care Team (CCT) is made up of NHS healthcare professionals including Health Care Support Workers, Community Advanced Practitioners, Nurses, Assistant Practitioners, Physiotherapists, Occupational Therapists and Mental Health Nurses.
Our aim is to help you to remain at home and avoid unnecessary admission to hospital and assist in early discharge from hospital.
We can support you to receive care in your own home or in one of the inpatient intermediate care beds located at Castleberg Hospital.
The team work in partnership with everyone involved in your care, including you, your carers and family members.
We will support you to develop personalised goals based on what matters to you most in your recovery.
The team will work with you to enable you to return to your usual level of activities whilst we support you to build your confidence and independence.
Rehabilitation is a two way process, we will work in partnership with you to follow your personalised goal plan.
You will be assessed by a nurse or therapist who will discuss your needs with you and develop a personalised agreed plan of goals.
Your progress towards your goals will be discussed daily.
Team members will enable you to carry out tasks and every day activities identified in your goal plan and will share information with others in the team as necessary to help us co-ordinate what you need.
The team work closely with other services including GP’s, voluntary services, Carers Resource and existing care providers using Electronic Health Records.
Following on from the care we have provided. If you have longer term care needs we will refer you to social services for enablement support or care provided by a care agency with your permission.
The team can provide intravenous antibiotic therapy for people in their own homes to avoid unnecessary hospital stays or to support you to leave hospital sooner.
Our patients are referred in from community sources such as GP’s, Community Matrons, District Nurses, Social workers, ACP’s (Advanced Community Practitioners), ED (Emergency Department) and FEP (Frail Elderly Pathway), referrals from acute settings such ward staff, hospital therapists and hospital consultants to support hospital discharge and YAS (Yorkshire Ambulance Service) for follow up falls assessments after they have attended…these are all electronic referrals received through the Hub.
YAS desk referral will refer directly to CCT’s via telephone to the CCT office number if they have a patient who has fallen and is currently on the floor, they will have been triaged as not having sustained an injury therefore assessed as safe for CCT’s to attend and pick up with/without use of lifting equipment.
YAS paramedics will refer directly to CCT’s via telephone to the CCT office number if they are in attendance at an address and deem the patient as not needing ED attendance/hospital admission but does require support to maintain their safety in their own home, reason for direct call is there is limited time for the paramedics to wait for a response via the hub which risks them needing to take the patient to hospital.