Home Visiting Service
The home visiting service provides coverage across a population of 390,000.
The service runs five-days-a-week, 8am-6.30pm, and covers all people in a neighbourhood who are currently unable to leave home without support.
These tend to be individuals, living at home or in care homes, with complex health and care needs.
They are cared for by a multi-disciplinary team which includes GPs, community enhanced practitioners, advanced nurse practitioners, and paramedics. Following triage, the person is visited by the appropriate professional for their needs.
A holistic assessment is carried out which seeks to identify and address all of their care needs.
Complex Needs Service
The Complex Needs Service aims to help individuals with complex medical, psychological and social issues who services are struggling to manage.
Referrals can be from GPs, Social Care, District Nursing, Home Visiting Service, East Midlands Ambulance Service or any other services.
After referral, patients are assessed by a community GP and aims of intervention identified and appropriate services involved.
Cases are then reviewed in regular Derby City Multi-Disciplinary meetings, with input from East Midlands Ambulance Service, Accident and Emergency, Social Care, Local Area Coordinators, Social Prescribing, Health and Well Being Coach, District Nursing, Mental Health, Community Therapy. Actions are identified and service gaps explored.
Following involvement with appropriate services there is ongoing review from the Complex Needs Service team and the Multi-Disciplinary team until discharge agreed.
Enhanced Health in Care Homes
EHCH stands for Enhanced Health in Care homes and is a service used throughout the city. It ensures that any individual living in a residential / care home are having their rights maintained and helps to improve the health of residents, and work with them to plan their proactive and personalised care.
Each care home has a weekly check up with residents, prioritised for a review bases on MDT clinical judgement and care home advice. Each Care home is also aligned to a PCN (Primary Care Network) and has a clinical lead.