The team deals with all clinical conditions for patients with complex needs providing appropriate discharge care plans.
Working closely with acute and primary care colleagues providing specialist nursing assessments. Establishing the level of nursing care needed and identifying the appropriate pathway e.g. Funded Nursing Care or Continuing Healthcare. The team will identify the appropriate destination for the patient and can give support and advice to family members regarding the availability of homes within their chosen area. The assessment includes provision of equipment for patients who are discharged home or into 24 hour residential care. The team also undertakes fast track Continuing Healthcare assessment, supporting the patient and family to identify a suitable discharge destination and providing an appropriate safe plan of care.
We review the needs of those patients admitted to hospital from Nursing or Residential homes to establish whether their current placement remains appropriate. The team also provides support to colleagues within the acute and primary care sector around the discharge planning process.
- Specialist Nursing assessments.
- Continuing Health care screening.
- Fast track Continuing Health care assessments.
- Review of patients from Nursing/Residential Homes.
- Provision of mattresses and cushions to patients’ homes or residential homes.
- Advice and support to the patient, trust colleagues, adult care colleagues, family members and the private sector.
Community Nurse Assessors
Integrated Discharge Team
Pennine Acute Hospitals NHS trust
North Manchester Genral Hospital
Tel: 0161 720 2800
Service Leads/Key Clinical Staff
Yvonne Casson – General Manager
Carol Kavanagh – Service manager
Claire Sutton Pilkington – Team Leader