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Community/District Nursing

The District Nurse (DN) service provides high quality Nursing care to individuals in their own homes, residential care environments and in the District Nurse Treatment Clinics across Plymouth. The service works in partnership with service users, their carers and other Health and Social care professionals.

The Community / District Nursing team works very closely and in collaboration with primary healthcare teams, which include your General Practitioner, Practice Nurse, Public Health Nurses and other professionals allied to the health service.

The District Nursing teams are each led by a District Nurse (DN) Team Manager and include District Nurses, Community Sisters/Charge Nurses, Long Term Conditions Matrons, Community Registered Nurses, Assistant Practitioners, Community Nursing Assistants, Nursing Auxiliaries and Phlebotomists.

Across Plymouth, the District Nursing teams provide both in hours and Out Of Hours nursing care, with teams available 365 days per year.

Livewell Southwest District Nursing teams are geographically linked with GP surgeries. Your will be seen by the District Nurse Team closest to your area.

The District Nursing service will triage referrals from anyone who contacts them, such as relatives, neighbours, carers and other professionals, such as GP's and Social Services.

 

Referral criteria:

The service is available to patients aged 18 or over who are registered with a GP and who are housebound as defined as:

  • Those people with a long term condition that prevents them from leaving their home
  • Those people who are medically compromised in the short term for a prescribed period and are unable to leave their home
  • Those people who for medical reasons are unable to attend the surgery due to their needs and / or clinical risk to the patient, for example immuno-compromised patients due to chemotherapy


Patients under 18 will be considered for the DN service with the support of a Children's Community Nurse through transition.



Referrals:

  • All urgent referrals will be received by telephone and triaged by the receiving nurse within 4 hours of documented receipt of referral
  • Non urgent referrals will be clinically triaged within 24 - 48 hours of documented receipt of referral and date for visit agreed
  • Routine referrals will be clinically triaged within 1 - 3 days of documented receipt of referral and date for visit agreed
  • Post-operative visit - access to service on specified date
  • Timed visit - for specified medication request only

 


Aims & objectives of the service

To provide:

  • A responsive service to meet the needs of adult patients registered with a GP to remain in their own homes, maximise their independence and improve their health outcomes and quality of life
  • A pivotal role in assessment, case management, and provision of general nursing care and delivering tailored care plans to meet individual health needs
  • Quality care for all adults referred to the service working in an integrated way with primary and social care to deliver patient centred care
  • Effective communication across critical, professional interfaces including primary care, social care, specialist services, virtual ward, voluntary care organisations, secondary and intermediate care services, placing the patient, their family / carer at the centre 
  • Support to avoid unnecessary admission to secondary care
  • Support to reduce admission and readmission by supporting and educating patients, families and carers to seek early intervention for potentially debilitating conditions
  • Facilitation of early discharge from acute providers and residential care
  • Support to enable patients who have long term and degenerative conditions to continue to live as independently as possible in their own homes
  • A fundamental role in enabling and supporting adult patients to die in their preferred place of death
  • Support to address the wider health needs of differing client groups and their families and carers to include health promotion, promoting healthy lifestyles and prevention
  • Support the prevention of ill health by engaging in the Department of Health immunisation programmes

 


Discharge criteria:

Patients will be discharged from the service when:

  • The treatment and care received by the patient has achieved the desired outcome(s) set by agreed realistic aims in partnership with themselves.
  • They can safely self-manage. All patients where capable will be supported to undertake self-management of their condition and discharged when this is achieved.
  • They are transferred to another more appropriate service e.g. social services, podiatrist.
  • They move out of area.
  • Patient has died.
  • They do not fulfil referral criteria following initial assessment.
  • They are not willing to engage in a jointly agreed plan of care. In these instances patients should be referred back to the GP with the offer of a joint meeting to plan the way forward.
  • Where they no longer require case management if determined not eligible to receive CHC funding, or where the DN no longer has the required skills to undertake the case management function


The patient and DN will agree when no further nursing or case management visits are required and the patient will be given a contact number for the service should they experience problems related to the episode of care. The DN will be responsible for ensuring that contact is made with relevant professionals to advise on discharge from the service and that prior to discharge, if necessary, the more appropriate practitioner has accepted the patient onto their case management list

Contact

North Plymouth Locality DN Team 

Tel: 01752 436716
Office hours: 8:30am - 5pm

 

East Plymouth Locality DN Team
Tel: 01752 434546
Office hours: 8:30am - 5pm

 

South Plymouth Locality DN Team
Tel: 01752 434851
Office hours: 8:30am - 5pm

 

West Plymouth Locality DN Team
Tel: 01752 434423
Office hours: 8:30am - 5pm

 

Urgent Care Locality - Out of Hours DN Team 
Tel: 01752 434427 (non-referral line)
All referrals to the Out of Hours District Nursing team need to be made via the Devon Doctors referrals line on 0845 241 9130.

The Out of Hours Plymouth District Nursing Team also provide Out of Hours cove for the areas of South Hams and West Devon between 19:00 - 7:00.


Treatment Clinic - Cumberland Centre
Tel: 01752 434625
Office hours: 9am - 5pm

 

Treatment Clinic - Local Care Centre
Tel: 01752 434802
Office hours: 9am - 5pm

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