Services to Support Admission Prevention in Ipswich and East Suffolk Version 0.3 COVID-19 Please refer to the Directory of Services for more information
Service How to refer Service How to refer Care Co-ordination Centre (CCC) Hours: 24/7 Interface Geriatrician Hot Phone for Advice Ipswich Hospital Single point of referral for the Integrated Neighbourhood Teams Tel: 0300 123 2425 Hours: (INTs) providing community health and Phone held by consultant geriatrician 9am-5pm Mon-Fri 09:00-17:00 care services, including access to Email: Mon - Fri community nursing and therapy, falls [email protected] Clinician to clinician discussion to agree suitable Tel: 07930 181236 assessment and management, urgent approach for patient in-hours social care response, specialist Referrals will be triaged to the most Advice provided and face to face assessment nurses, equipment provision and home appropriate team. For community matron arranged for patient if required on FAB (see support. The COPD Service & REACT are referrals see last page. below) also accessible via the CCC (see below).
Reactive Emergency Assessment Hours: 24/7 Community Team (REACT) Core team available 08:00 - 20:00 365 days a Frailty Assessment Base (FAB) Hours: Multi-agency team (health, social year Mon-Fri 08:00-18:00 care and VCS) to reduce avoidable Located at Ipswich Hospital ED attendances /admissions Tel: Care Co-ordination Centre on 0300 123 Tel: via Geriatrician hot phone: Short term support for adults (18 2425 and request REACT Multidisciplinary comprehensive geriatric years +) in crisis situations assessment for frail individuals (frequent fallers, 07930 181236 new onset of immobility, acute confusion) at risk of Urgent assessment can be REACT comprises nurses, occupational arranged within 2 hours therapists, physiotherapists, health care acute admission Email: [email protected] REACT can access an Interface assistants, generic workers, British Red Cross • Assess in FAB with aim to clarify medical stability Geriatrician via the Frailty and Suffolk Family Carers support workers. and avoid hospital admission where possible Assessment Base (FAB) and step up • Aim to support patients within their current place of FAB is currently closed to community beds. residence during COVID-19 Designated care homes team now FAB can step patients up into community beds if they available are not safe to remain at home, but do not require an acute hospital bed. Provides short-term primary, secondary and community care • Assessment within 48 hours in FAB at Ipswich approach for patients with nursing Hospital needs, to be treated in their own Urgent assessments can take place following home and to prevent an acute discussions with geriatrician via hot phone (see admission. above) • The team comprises geriatricians, nurses, OPAT (Outpatient Parenteral Hours: Mon- Fri 08:30-16:00 pharmacists, physiotherapists, healthcare assistants Antimicrobial Therapy) Referrals for OPAT via primary care for GP • Works closely with REACT to provide wrap-around care to support patients to remain in the community REACT hosts the OPAT service to support and then ring Rushmere Day Unit wherever possible. manage the delivery of (Ipswich Hospital) intravenous antibiotics to patients who are medically stable, within their own homes. Tel: 01473 707682 option 2.
Services to Support Admission Prevention in Ipswich and East Suffolk Version 0.3 COVID-19 Service How to refer Service How to refer Suffolk COPD Service 7 days per week Suffolk Family Carers Hours: Patients ≥ 18 years with a confirmed diagnosis of Mon-Fri: 08:00-18:00 COPD, being treated with antibiotics and/or Sat/Sun: 08:00-16:00 information line Mon, Wed, Thurs 9:00-17:00 prednisolone for an acute exacerbation BH: 09:00-17:00 Support services for family carers Tues 9:00-19:30, Fri 9:00-16:30 Same day assessment for acute exacerbation offering Information, advice & of COPD guidance to adult carers. Ipswich Tel: 0300 123 2425 and request Hospital has a carers’ cabin onsite. Tel: 01473 835477 Home oxygen assessments (excluding End of the COPD service Life) Carers assessments are accessed via Community Hospitals Customer First Aldeburgh Tel: 01728 451636 0808 800 4005
If your patient is at risk of admission and would be REACT: Via Care Co-ordination Centre on suitable for a period of short term reablement, Felixstowe REACT also has SFC as part of their 0300 123 2425 and request REACT please refer to REACT (see above) who will be able service 08:30-16:30 Mon-Fri. to assess and access these beds if appropriate. Tel: 01394 458820 *Short Term Assessment, Reablement and STARR* Centre at Bluebird Lodge, Hours: Rehabilitation Centre (STARR) Ipswich British Red Cross Tel: 01473 322100 In REACT the BRC service is provided: End of Life Co-ordination Centre including The British Red Cross (BRC) offers Mon-Fri 08:00-18:00 plus some weekend cover. EOL Co-ordination Centre via short-term practical and emotional Specialist Palliative Care Advice: OneCall OneCall – 24/7 (During COVID) support at home, to help people regain their independence. For community referrals Enhanced service during Covid-19, Tel: 0800 567 0111 Tel: Care Co-ordination Centre on coordinating EOL care in the community The REACT service has British Red 0300 123 2425 and request the REACT team. through OneCall Cross volunteers as part of their Rapid response visiting capability in and out of service, so community referrals should hours (via REACT and hospice reactive team) be made to this team via the CCC. Includes hospice and palliative care support from St Elizabeth Hospice, Ipswich BRC Supported Discharge Advice and support for patients, families and Ipswich Hospital also has a BRC team clinicians in the community that supports discharges from acute Patient does NOT need to be known to the wards (01473 702485) hospice to gain support Customer First 24/7 Out of hours calls diverted to Emergency Acute Oncology Service (AOS) Hours: Duty Service Clinical Nurse Specialist: First point of contact for social care Mon-Fri: 08:00-16:00 enquiries and referrals for Suffolk. Tel: 0345 606 6167 Based at Ipswich Hospital (ESNEFT) Sat/Sun 08:00-13:00 They deal with adult and children’s MASH professional consultation line: Clinical Nurse Specialist Referral via hospital switchboard services, AMHP referrals, adult 0345 606 1499 Bleep 651 / Ext 5900 safeguarding and child protection, Online: Consultant Oncologist on call https://www.suffolk.gov.uk/care-and-support- and have a dedicated MASH for-adults/how-social-care-can-help/contact- adult-social-care/ Tel: 07903 049003 Professional consultation line to Consultant Oncologist on call via support queries around these areas. www.suffolk.gov.uk/adultsafeguardingreferral hospital Switchboard 24/7
Services to Support Admission Prevention in Ipswich and East Suffolk Version 0.3 COVID-19 Service How to refer Service How to refer
Hours: Mon – Fri 09:00-17:00 Access and Assessment Team Hours: Mon-Fri 8am to 8pm Dementia Intensive Support Team
Tel: 0300 123 1334 (DIST) Advice and assessment on all mental health conditions across all ages including suicidal intent Healthcare advice, assessment or support - Tel: 01473 891733 Triage, assessment and signposting of referrals known or suspected dementia. within agreed time limits -Patients in the community and acute hospital 07852 769172 presenting with a dementia related crisis due to a Team do not provide long term treatment but can change in behaviour, delirium or care breakdown. carry out referrals to other mental health teams This team is now based in the community with following assessment, if needed. REACT and will cross-refer between teams if required.
Suffolk Wellbeing Service: Living Life to Online: https://llttf4suffolk.com/ Hours: The Full Turning Point: Drug and Alcohol Support Services Mon 10am-3pm Living Life to the Full (LLTTF) is a life skills course To access the resources, people Tues 1pm-3pm need to complete the mood quiz. that aims to provide access to high quality, There is the option for support Wed, Thurs, Fri: 10am-3pm practical and user-friendly training in life skills Integrated substance misuse for county. Support from an IAPT worker at Wellbeing services for drug and alcohol recovery. using award winning CBT treatment tools Suffolk if required. Tel: 01473 220240 enabling people to tackle and respond to Referrals for age 25 and above. issues/demands which we all meet in our everyday lives. Courses cover low mood, stress, anxiety and Stay Alive App resilience, how to tackle problems, build confidence, get going again, feel happier, stay calm, and more. There are resources specific for people with long term conditions including chronic pain and perinatal resources too. Hours: The service runs 7 nights Suffolk Night Owls per week from 7pm to 1am.
Tel: A telephone, text and email support service for To use the line people need to anyone who needs emotional support including register online at: those with complex emotional needs. www.suffolkmind.org.uk/services Support line workers will be there to listen and Once registered, individuals are support individuals. They have experience of contacted and given a number to working within mental health services. call which can then be used for A place to get impartial support and information support during the times of crisis. in a non-judgmental way.
Services to Support Admission Prevention in Ipswich and East Suffolk Version 0.3 COVID-19 Service How to refer Service How to refer
Emergency Assessment Unit (EAU) Hours: Community Matrons Hours: 24/7 Mon-Fri 09:00-17:00 All urgent or emergency medical patients Support patients with multiple long term conditions, whose are seen, assessed and a decision is made Tel: 01473 712233 and ask needs are complex and are at Email: whether they can be discharged or need to for bleep 620. risk of admission or re-admission Complete referral form available on DXS or email stay in hospital. After 5pm ask for ‘medical to the acute services. Provide Care Coordination Centre on: admissions’ and speak to the case management support, [email protected] on-call consultant. Referrals are accepted from GPs and ED. helping patients to recognise, understand and self-manage Referral criteria: their condition to promote independence and improve the The patient will have 3 long term conditions and patient’s quality of life. 2 or more of the following: Surgical Assessment Unit (SAU) Hours: 24/7 3 or more admissions to hospital in last All urgent or emergency surgical patients 6 months are seen, assessed and a decision is made Tel: 01473 712233 and ask 3 or more A&E attendances last 6 whether they can be discharged or need to for ‘on-call surgical registrar’ months (especially for the same stay in hospital. (bleep 182) reasons) 2 or more falls in the past 2 months Referrals are accepted from GPs and ED. Recent admission > 4wks duration High user of GP services Suffered a bereavement within the past year and are at risk of medical/social decline Paediatric Assessment Unit (PAU) Hours: Mon-Fri 09:00-23:30 People taking 5 or more medications Sat/ Sun 12:00-18:30 Pediatric referrals from GPs, Midwives, Health Visitors or Community Nurses. Outside of these hours via Bergholt ward
Tel: 01473 702198
Hours Emergency Gynaecology Mon – Fri 08:00-16:00 Assessment Unit (EGAU) Out of hours via on-call SHO (bleep 397)
Early pregnancy pathway. Referrals from GPs, midwives & ED. Tel: 01473 703671