Formerly known as Virtual Ward, the Community Care team provides co-ordinated health and social care for patients who are at high risk of emergency admission to hospital – such as those with long term conditions and frail or vulnerable older people.
You stay in your own home and all the different members of the team meet regularly to help you manage your condition, keep you well and prevent you from being admitted to hospital unnecessarily.
The team has health and social care professionals who work closely with GPs. This includes district nurses, community matrons, medicines management, therapists, health care trainer and a social worker.
The team will be able to access extra advice and help from a range of services that are appropriate for a patient's care. This may include heart failure nurses, respiratory team, diabetes team and dieticians.
Again much like a ward environment patients will be referred if necessary but may not need input from all of these services.
The team will meet fortnightly but communicate regularly to identify any patients who require visits or discuss any changes to the care of patients. Any changes will be discussed with patients and an individualised plan put in place.
There are four team in South Sefton:
If the team and your GP believe you will benefit from an increase in support for a long term condition(s), or if you have been referred for a specific treatment or care, and if you are over 16 and registered with a South Sefton GP .