Our aim is to support our patients to remain out of hospital and be supported at home if that is their wish.
Patient with complex medical problems are identified by using a specially designed ‘risk stratification tool’, incoming hospital communication and also through soft intelligence from the GP team and other medical services.
We will then send the information about the service to the patient by letter and invite them to attend an extended appointment with our PYC Lead Nurse or a home visit where appropriate. Whilst making this appointment the administrator will provide the patient with additional information about the PYC service, the benefits of the Communities of Practice tram and also ask the patient for their consent to share their medical information with other medical services.
A comprehensive care plan for the patient will be completed by the PYC Lead Nurse. This meeting will be called a ‘Planning Your Care’ appointment. Family/Carers/loved ones will also be encouraged to attend this appointment if this is what the patient wishes. Important medical information will now be seen by other medical professionals, with the patient recorded consent.
Your wishes and preference for your preferred place of medical care and the place you would wish to die will be documented, this information will be part of individual patient care plan.
The patient will be offered the opportunity to be referred to other relevant medical or voluntary service’s for support during this appointment.
The patient’s medical records will be completed and a printed copy will be given to the patient for them to keep in a purple wallet. This wallet will be given to the patient by the PYC Lead Nurse at this appointment and will be a reference for both the patient and the health care professionals involved in their care. The patient will be encouraged to keep all clinical documents and correspondence in this purple wallet and take this to all their appointments. Family, friends, loved ones/carers should be informed of the location of this wallet. If the emergency services are called to the patient’s home, they will become familiar with the purpose of this purple wallet.
Referral to other services such as COP/Hospice/Carers Support/Falls Prevention/Age UK/Nutritionist/Time to Talk are encouraged by the PYC Lead Nurse.These services have capacity and are very willing to support our patients and their loved ones. Relatives may become carers without realising it, this service offers information and support to help when caring for someone.