Urgent Community Response (UCR) teams provide urgent care to people in their home which helps to avoid hospital admissions and enable people to live independently for longer.
Through these teams, older people and adults with complex health needs who urgently need care, can get fast access to a range of health and social care professionals within two hours. This includes access to physiotherapy and occupational therapy, medication prescribing and reviews, and help with staying well-fed and hydrated.
There are 9 pillars within the Urgent community response for teams to respond this are
|With no apparent serious injury, including to the head, back, hip, or where able to rule out a fracture, and where there has been no loss of consciousness.
|Decompensation of frailty
|A frailty-related condition which may result in loss of strength, speed, energy, activity, muscle mass, resilience to minor health strains and subsequent loss of independence.
|Decompensation caused by a minor stressor event, such as a urinary tract infection (UTI), that can cause a sudden or disproportionate decline in function.
|Reduced function/ deconditioning/reduced mobility
|The person may have a gradual change in functional ability or ability to manage at home and with activities of daily
|living. Mobility loss can also be sudden, leading to an acute need.
|Palliative/end-of- life crisis support
|If core palliative/end-of-life care services are not available to respond, a crisis response service will help maintain a person close to the end of their life at home, offering symptom control/pain relief in line with a person’s wishes.
|Urgent equipment provision
|Alongside an assessment, makes a person safe and optimises functional ability to support prevention of admission. A person should be made safe and ongoing care provided where appropriate by reablement or rehabilitation services.
|Increased or new confusion, acute worsening of dementia and/or delirium (excluding sepsis requiring hospital admission). The patient should be assessed and physical health needs managed to establish the cause (eg UTI, cellulitis, pneumonia) so that their needs are managed safety at home.
|Urgent catheter care
|Where a person has a blocked catheter and/or pain from a catheter-related issue and is at risk of harm and has a very high risk of admission to hospital. Where a district nurse service hasn’t the capacity to respond or is part of the explicit function of the crisis response team.
|Urgent support for diabetes
|Where the person has experienced a hypoglycaemic episode (now resolved) or where blood sugar management is a concern and the person is at risk of hospital admission as a result (excluding sepsis requiring hospital admission hyperglycaemia/ketoacidosis).
|Unpaid carer breakdown which if not resolved will result in a health care crisis for the person they care for
|Provide healthcare where a carer who meets a person’s healthcare needs is no longer able to do this and the person they care for now requires a two-hour crisis response.
|Where crisis response teams identify social care needs rather than healthcare needs – for example, where carer stress means a carer is unable to provide safe care or where either the carer or cared for person is experiencing abuse or neglect – they should:
|· make an urgent referral to the relevant service where the crisis response team does not have Care Act 2014 responsibilities
|· provide care in line with the Care Act 2014 where the crisis response team does have Care Act responsibilities
|· work jointly with local authorities or care providers.
Information About Existing Teams
Within Somerset NHS Foundation trust, it is the existing teams within the primary care and neighbourhood directorate that provide an interconnecting model to support Urgent Community Response. These teams include:
- Rapid Response Service (RRS) who have had additional resources to increase capacity to ensure response time. They will pick up the additional new pieces of work such as the Falls Pillar of UCR, already have existing pathway for a couple of pillars and already have a 2 hour response time frame as part of service specification. This will include pharmacy technician roles.
- District Nursing Service (DN) provide an existing pathway for a couple of the pillar and already have 2 hour 2 hour response time frame as part of service specification.
- Intensive Dementia Support Services (IDSS) provide an existing pathway for a pillar and already have a 2 hour response time frame as part of service specification.
The above services are not an exhaustive list of services, as UCR is an over arching aspect to the majority of Community services, however the above services all have a service response timeframe of 2 hours.
As part of the new funding the community service have also invested in Advance Clinical Practitioner (ACPs). These ACPs will support UCR workstreams along with Hospital @ Home work streams.
How To Refer
Referrals are currently not available for patient self referral.
Referrals for UCR will be taken via the existing route which is through Somerset Primary Link (SPL) between 8am and 8pm via 01749 836700, option 1.
Direct referrals can be made to local District Nursing hubs for End of Life support, Catheter and Diabetic support as per normal pathways – If you are unsure, SPL will take referral and divert to the most appropriate team post triage.
Urgent community response runs 8am to 8pm 7 days a week