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The Collaborative Care team is available 24/7, 7 days a week and is made up of a range of healthcare professionals: community nurses, advanced clinical practitioners, urgent community response practitioners, health care support workers, physiotherapists, occupational therapists and mental health workers – all focussing on the keeping the patient well and at home and avoiding the need for an admission to hospital.

The 2 hour urgent community response is one of a range of new initiatives from Airedale NHS Foundation Trust which aims to help keep people well at home and reduce pressure on hospital services.

The Collaborative Care team is available 24/7, 7 days a week and is made up of a range of healthcare professionals: community nurses, advanced clinical practitioners, urgent community response practitioners, health care support workers, physiotherapists, occupational therapists and mental health workers – all focussing on the keeping the patient well and at home and avoiding the need for an admission to hospital.

The team can assess any patient over the age of 18 within 0-2 hours of receiving a referral from a GP, community matron, district nurses or ambulance service or from the Trust’s own Emergency Department or Acute Assessment Unit.  Referrals are made to the team if the patient is safe enough to be at home but needs some extra support.

Common conditions that can be seen by the 2 hour response service include long term conditions where the patient has become acutely ill, falls with no sign of injury, reduced function,  mobility or confusion, palliative care support or an urgent need for equipment.

Sarah Emsley, Urgent Community Response Practitioner at Airedale NHS Foundation Trust says:

“As soon as we receive a referral we make contact with the patient to explain our service and to say that we would visit in 2hrs, because time is critical.  At the visit we do a full assessment of their needs to see whether we can keep them safely at home”.

“During the next 48hrs we can arrange continued support if they need help to recover and increase their independence, or if it’s a long term need then we’d work with our partners in social care or with one of many voluntary services.  This might be Carers Resource or Safe and Sound, they would help the patient have a pendant alarm fitted, if they were in any danger or might fall, they can press that button and get help when they need it.” 

Sarah continues:

“In May alone we saw 115 patients and we’ve helped 93% of those patients to stay at home, without the need for an admission.”

Patient case study

“One of our patients has COPD and had an exacerbation of his condition and was at risk of needing to be admitted to hospital so our respiratory nurse assessed him and asked us if we would visit him to help keep him at home.  He was using nebulisers four times a day so we were visiting once a day to check his observations and making sure he was using his nebuliser accurately and getting a good therapeutic dose.

We managed to help him at home and we identified other needs while we were there, for example he was struggling with his mobility and everyday tasks so we worked with him to try and overcome his breathing issues and how he could pace himself.  We referred him to the community rehabilitation team so we could look at how he could get longer term support. We also referred him to pulmonary rehabilitation to try and increase his exercise tolerance.

The benefit in our team is that we have a mental health nurse as well and he had some anxiety around not being able to breathe properly so we asked if she would visit him and look at any techniques to support his anxiety.

All of that happened within two weeks and he never needed to come into the hospital which was what mattered to him.”

The patient says:

“I was getting rapidly short of breath and so they came out to see me.  I wanted to stay at home, and their aim too is to keep me out of hospital and away from any potential infections.   Admission to hospital for me is an absolutely last resort.

“They gave some good advice and polished up my breathing technique again.  I have been shown before over the last couple of years, but when your mind goes into panic mode you tend to forget.  They gave me a refresher course and made sure I was ok going forward with my home treatment.

“They were cheerful and upbeat too, there was no ‘what have you been up to,’ everything about the whole approach was really positive.”