Adult Community Nursing

Provided by the Mid Yorkshire Hospitals NHS Trust (MYHT), the Adult Community Nursing Service (ACN) plays an integral part in supporting the health and wellbeing of residents in the Wakefield district and allows residents to be cared for as close to home as possible.

 

ACNs are part of the Community Nursing Team and are based within each of the GP Networks. They provide nursing care for adult housebound patients (in the setting where they reside) and those in residential care homes.

 

The ACN service is accessible 24 hours a day, seven days a week via the Single Point of Contact (SPoC), and uses agile mobile working in community settings to deliver patient-centred care through integrated working. The ACN services are central to the capacity of individuals to remain in their own homes and communities and therefore aim to:

  • Provide holistic care for all adults referred to the service, designing and delivering tailored care plans to meet individual health needs, which is evaluated, monitored and reported
  • Enable patients with long term and degenerative conditions to continue to live as independently possible in their own home
  • Avoid unnecessary hospital admissions
  • Facilitate early discharge from Acute Trust Providers and prevent admission to long
  • term residential care
  • Support patients and families in fulfilling their goal of dying in their preferred place of death and supporting the delivery of choice at end of life
  • Deliver a service which communicates effectively across critical professional interfaces, including: Primary Care, Acute Sector, Adult Social Care, Integrated Discharge Teams, Third and Voluntary Sector (not exhaustive), placing the patient at the centre
  • Work with other Health and Social Care providers to support Continuing Healthcare (CHC) assessments in nursing home settings and undertake fast track CHC assessments as the ‘eligible clinician’
  • Participate in the application of the NHS CHC framework including checklists and the MDT approach to Decision Support Tools (DSTs) in cases where Adult Community Nursing input is required, including in the patient’s home.

 

The interim ACN service specification was rolled out in April 2016. It has been developed in review of the policies, procedures and training requirements of both primary care and ACN as a whole. The specification has addressed the different roles, responsibilities and skills required from Adult Community Nurses, redefining their role in the delivery of nursing services, whilst identifying key objectives and deliverables in line with local and national requirements.

 

This specification has therefore shaped the way the ACN Service is currently being delivered across the Wakefield district, and will support the full revision of the ACN service specification, which will be carried out as part of the wider integration agenda in the future.

 

Since April 2016, all education and training required across the ACN and Primary Care specification has been reviewed and planned.

 

Training completed has included; Ear care training, which was accessed by a total of 109 staff, from MYHT and from 37 of the then 40 GP practices and wound care training which was accessed by 96 staff from MYHT, care homes and from 33 of the then 40 GP practices.