Extra support at home for patients over the age of 65 who leave hospital
All Dudley patients over the age of 65 will now receive a telephone call after they are discharged from hospital to see if they need extra help and support at home.
A team of ten MDT care coordinators, employed by The Dudley Group NHS Foundation Trust, can help patients with anything from benefits to carers support, home repairs to community fire prevention, and any other health or social care needs.
“We are really excited about the role of the care coordinators because they can ensure vulnerable patients feel settled and sorted once they are out of hospital and back at home,” said Paul Bytheway, Chief Operating Officer for the Trust.
“They provide patients with a vital link between the hospital, their GPs and other community-based services, and we hope this will help them to live independently and remain in their own homes,” he added.
One patient who has already received help from a care coordinator is Ronnie Myatt, 81, from Brierley Hill.
“I was delighted when Karen called to check how I was managing at home. It gave me real peace of mind to know that someone was thinking about me and was interested in my recovery,” said Ronnie.
The MDT care co-ordinators are funded through the national new care models money awarded to Dudley to develop a Multi-speciality Community Provider (MCP).
The coordinators are based at Brierley Hill Health and Social Care Centre and work with the multi-disciplinary teams at each GP practice to determine which patients are most frail or vulnerable and in need of a follow up phone call.
They will also discuss people who visit hospital frequently, and use the meetings to consider prevention plans and community services to support them so they can remain in their own home.
Once fully established the care co-ordinators will be the pinnacle of the MDT, being the glue that binds the MDT together.
Dr Steve Mann, Clinical Lead for MCP Development, Dudley CCG: “We see care coordinators as a vital part of the development of our model of care, bringing essential organisational skills and ensuring that our teams of health and care professionals work effectively in a coordinated fashion. We have listened to what Dudley people said about their care provision not joining up properly and these roles will enable the smooth transition of people coming home from hospital into their communities. These are exciting times for healthcare in Dudley especially with the development of our new MCP, healthcare organisation.”