Helping people remain independent is a key priority for health and social care organisations in Norfolk. To achieve this, work is taking place across the county to ensure people have access to the care and support they need within or closer to their own homes. The services described below are examples of how the CCG is seeking to reshape care around local needs in North Norfolk and rural Broadland.
Supported Care Service
The Supported Care Service aims to keep frail patients at home and help them to maintain independence for as long as possible. The service provides immediate response, short term (up to seven days) wrap around reablement care with nursing and therapy oversight. The service is aimed at frail patients, such as those who have unstable long term conditions or at risk of acute infections, requiring an immediate combined health and care response to avoid being admitted to hospital or support when discharged home to avoid readmission. The model also includes a voluntary and community sector co-coordinator to connect the health and care response with the voluntary sector and wider community.
Hospice at Home
The service is aimed at palliative and end of life patients in the community who are experiencing acute or rapid deterioration in their health. The model focuses on community based provision to support patients more responsively to remain in their preferred place of care and reduce inappropriate and avoidable admissions in the last year and days of life.
- Nursing and Occupational Therapy staff with enhanced palliative care knowledge of symptom control & pain management providing clinical oversight, assessment and review including the ability to deliver advanced clinical interventions and provide proactive support to make necessary lifestyle adjustments.
- Support Workers with enhanced palliative care knowledge of what to expect, how best to support patients, including managing symptoms and when to escalate to clinicians.
- Compassionate Communities where every community is prepared to care. Connecting health and care with the voluntary sector and wider community such as Hospice Neighbours. The plan includes a 24 hour emergency advice and information line will also be made available to carers.
Norfolk Escalation Avoidance Team (NEAT)
NEAT is a single point of access for urgent, unplanned health and social care needs where an integrated immediate response is co-ordinated from across the health and care system. Participating organisations include;
- NCH&C (Norfolk Community Health and Care NHS Trust)
- Norfolk County Council Adult Social Care
- Norfolk First Support – reablement service
- NSFT (Norfolk and Suffolk Mental Health Trust)
- Supported Care Service – admission avoidance service
- North Norfolk Primary Care