Community Nursing (DRAFT)

Overview

What do we do?

Sirona care & health provide clinical care and support to help people stay well for as long as possible in their own homes.

We help to:

• Reduce unnecessary admissions to hospital.
• Facilitate timely discharges from hospital back to individuals place of residence.
• Allow people to stay out of long-term care for longer.
• Reduce people needing to go into residential and nursing homes.
• Provide rehabilitation to promote health and independence.
• Improve people’s experience of healthcare.
• Support people at the end of life to die in their preferred place of care.

Our integrated teams bring together community nurses, occupational therapists, physiotherapists, paramedics and support staff to work as one team to serve a local area. These teams work alongside Primary Care to provide clinical care for people in their home or in a site in the community.

Who do Sirona care & health support?

We provide services to adults over the age of 18 years, registered with Primary Care within Bristol, North Somerset or South Gloucestershire who are unable to access clinics or primary care service due to their health. The type of support provided by the teams is targeted to meet the individual needs of people, their carers or family.

Our pathways

Sirona care & health provide an integrated service 7 days a week, 24 hrs a day that supports patients in the following areas of care:

• Community Nursing 
• Urgent Community Response
• Rehabilitation (Community Therapy)
• Support after Discharge from Hospital (Discharge to Assess)
• Out of Hours 
• Community Domiciliary Bloods 

Community Nursing Referrals

Community Nursing pathway operates between 8am and 8pm.

When making referrals please provide any relevant details including: consent of patient, access to property or carer details, situation and background of problem, clinical reason for referral and expected outcome where possible.

Urgent referrals - visit required within 48 hours:

Community nursing interventions where a visit is required within 48 hours must be phoned through to SPA on 0300 125 6789.

Non-urgent referrals:  

Via the Non-urgent Referral Form.

If the intervention is non urgent, a non-urgent referral form should be completed and emailed; except for Community Domiciliary Blood Referrals. You may also continue referring through EMIS Managed Referrals.

Community Domiciliary Bloods

The Sirona Community Services Domiciliary Bloods Referral Form is live on EMIS for the request of Amber or Green bloods.

The requester is responsible for following up and completing any actions.

Blood requests are colour coded:

•  Red: Required within 48 hours to avoid a hospital admission, to ensure safety, or to implement a change of treatment. Please note these should be phoned through to SPA on 0300 125 789. You cannot complete a form or make a referral through EMIS to request them.
• Amber: Bloods required between 48 hours and seven days.
• Green: Bloods required between eight days to six weeks.

There is a different pathway for Weston, Worle, and Villages.

• Red (urgent) blood requests should be phoned through to SPA – 0300 125 6789 - with an ICE Request.
• Non-urgent referrals should be made through the ICE pathology system.

Out of Hours Nursing Service

The Sirona care & health Out of Hours Nursing Service provides nursing care between 8pm and 8am

Referral process for external agencies into OOHs Clinical Team BNSSG (Brisdoc/SWAS etc.)

Contact SPA line: 0300 125 6789 if urgent night visit required.

Out of Hours Clinical Team referral criteria

• Palliative visits – patients who are in pain or unsettled, requiring pain relief/stat doses, family requiring support and guidance, syringe driver management – alarming or requires urgent attention, verification of death and end of life/grief and after death support for family.
• Blocked catheter/bypassing or acute retention in pain, patients at risk of Autonomic Dysreflexia.
• Clinical monitoring – with escalation processes and management plans in place.
• Time specific medication administration.
• Patients who have fallen, with no or minor injury.
• Wound care – open wounds, severe wound pain or discomfort, bleeding wound/heavy exudate or broken areas with cellulitis symptoms, urgent unplanned wound care (planned wound care should be undertaken within day working hours).

End of life Care - Community Support

Please see End of life care - community support  page for details and referral information.

Discharge to Assess

Discharge to Assess is the assessment and support given to people who are returning home after a period in hospital.  Community therapists and others provide support to people to continue their rehabilitation and recovery at home.

If you have a patient on this pathway and you want to discuss their case, please phone through to SPA on 0300 125 789.

Specialist Wound Care

Please see the Tissue Viability/Wound Care Service page for service details and referral information.

EMIS electronic prescribing charts

Community prescribing medication charts can be completed electronically in EMIS (BNSSG Community Drug Chart), without the need for a wet signature. For a PDF version of the chart, see BNSSG Joint Formulary (scroll down to the Healthier Together PSD section).

Community Insulin prescribing charts can also be completed electronically in EMIS (BNSSG Insulin Community Drug Chart), without the need for a wet signature. For a PDF version of the chart, see BNSSG Joint Formulary (scroll down to the Healthier Together PSD section).

Prescribing of end of life medication should not be done on these charts - these charts are available separately on the End of Life Care page.

The process we have agreed for the electronic drug chart use is:

For new referrals:

• GP or other primary care healthcare professional identifies patient will need an intervention requiring a PSD and completes consultation accordingly documenting fully on EMIS.
• GP completes community prescribing form on EMIS.

For urgent requests within 48hrs:

• The GP/HCP completes a referral to the Sirona SPA by phoning 0300 125 6789 and will advise the Health Navigator that the chart has already been uploaded to EMIS.

For routine requests over 48hrs:

• The GP/HCP completes a referral to the Sirona SPA by email or managed referral using the single referral form and stating that the chart has already been updated to EMIS. The email addresses for referrals are:
  • Bristol - bristolspa@nhs.net,
  • South Glos - sirch.southglosspa@nhs.net 
  • North Somerset  - sirch.northsomersetspa@nhs.uk.
• SPA will process the referral and may call the surgery back for further information if required. Please ensure that all forms are fully completed. Sirona staff in the community will print the chart(s) and use according to agreed process.

For updated charts:

Charts may require updating for a variety of reasons, for example changes in clinical condition requiring amendments to medication, or charts that are due to expire and so require updating.  Updates to charts may be initiated by INT teams or Primary care healthcare professionals. 

Whenever charts are updated, the previous chart must not be overwritten and a new chart must be created and saved onto EMIS, so it remains visible and provides a complete clinical record.

When INT teams request updated charts urgently, community staff may telephone the surgery, or otherwise email the surgery receptions generic email address.

When contacting the surgery, they will provide:

• Individual details – patient name, DOB/NHS number, medication requested and why
• Any further useful information
• By when does this need to be prescribed (deadline)?

The surgery will then arrange for the chart to be completed by a prescriber and uploaded to EMIS. The surgery should email or phone SPA to confirm that this has been done and the chart is available to print and use.

When Primary care healthcare professionals update charts due to changes to medication they should complete the community prescribing chart on EMIS.

1. For updates required same day, phone Sirona SPA 0300 125 6789 and advise the Health Navigator that the chart has been uploaded to EMIS.
2. For all other updates, email Sirona.  The email address is: sirona.psd@nhs.net
3. SPA will review and may call the surgery back for further information if required
4. Sirona staff in the community will print the chart(s) and use according to agreed process

For secondary care and other providers not on EMIS the charts should be sent to sirona.psd@nhs.net with all the relevant information attached.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.