EMed

Acute & Community Services to support discharge: CUH

Acute & Community Services to support discharge

Service Description Contact
Liaison Community Support Team (LCST)

Inclusion criteria:

Patients in CUH, MUH, SIVUH, SFH and UHK who are >65 years old can be referred to LCST for:
  1. Home support packages (HSP)
  2. Interim HSP
  3. Transitional care beds (TCB
  4. Rehab (Kerry Only)

Referrals:

The "Single Referral Form" for LCST should be completed (located in the staff directory under referral forms "Integrated Discharge Referral Form 2023")		 LCST.Cork@hse.ie,
LCST.Kerry@hse.ie
Public Health Nursing (PHNs)

Inclusion criteria:

Patients following an acute admission, who are >75 years of age, or have ongoing nursing needs. To identify the correct PHN email, insert the patents Eircode into the HSE Area Finder Map

Referrals:

The "Single Referral Form" for PHN should be completed (located in the staff directory under referral forms "Integrated Discharge Referral Form 2023")

Kerry:


northkerry.phn@hse.ie
westkerry.phn@hse.ie
southkerry.phn@hse.ie

North Cork


Northwestcork.phn@hse.ie
Northeastcork.phn@hse.ie
eastcentralcork.phn@hse.ie

North Cork City


eastnorthcity.phn@hse.ie
Northcorkcitycentral.phn@hse.ie
Northcorkcitywest.phn@hse.ie

West Cork City


Westcork.phn@hse.ie

South Cork City

blackrockdouglas.phn@hse.ie
westcentralcork.phn@hse.ie
Bandonkinsalecarrigaline.phn@hse.ie
Complex Case Management Team (CCMT)

Inclusion criteria:

Complex patients between the ages of ≥18 and ≤65 years, who are encountering barriers to discharge.

Referral:

The "Single Referral Form" for CCMT should be completed, and emailed to the CCMT.

 ccmt.south@hse.ie
Service Description Contact
Community Health Networks (CHN) Each CHN has a weekly Clinical Team Meeting (CTM), where members of the multi-disciplinary team (including GPs, clinical coordinators, allied healthcare professionals, nursing, and home support workers) discuss patients care needs and implement treatment plans.

Referral:

There is no referral form. Send the patient details and relevant clinical information to the appropriate CHN email address. To select the correct CHN email address, input patients Eircode or address into the HSE Area Finder Map.

Kerry

northkerry.chn@hse.ie
westkerry.chn@hse.ie
southkerry.chn@hse.ie

North Cork

northwestcork.chn@hse.ie
northeastcork.chn@hse.ie
eastcentralcork.chn@hse.ie

North Cork City

eastcorkcity.chn@hse.ie
northcorkcitycentral.chn@hse.ie
Northcorkcitywest.chn@hse.ie

West Cork City

westcork.chn@hse.ie

South Cork City

blackrockdouglas.chn@hse.ie
westcentralcork.chn@hse.ie
bandonkinsalecarrigaline.chn@hse.ie
southcorkcitycentral.chn@hse.ie
Community Intervention Team (CIT)

Inclusion criteria:

16km radius of Cork City, Mallow and Middleton
  1. 32km radius of Cork City, Mallow and Middleton for I.V. antibiotics
  2. Patients referred for I.V. antibiotics must be administered with two doses I.V. prior to CIT commencing
  3. Treatment centre available to those living outside the catchment area.

Exclusion criteria

  1. Chronic illnesses requiring > 72 hours treatment (Excluding I.V. antibiotics)
  2. Patients experiencing acute episode of mental illness
  3. I.V. fluids and blood transfusions
  4. Under the influence of illicit drugs or alcohol
  5. Under 16 years of age
  6. Residents outside the catchment area and unable to travel to treatment centre.

Cork:

0818 837427,
admin@southwestcit.ie

Kerry:

086 7872483,
cit.kerry@hse.ie

Service Description Contact Details
Outreach Team – Older Adult Home rehabilitation service providing PT and OT rehab. and nursing support for patients > 65 years of age with acute care needs. These can be provided for up to 6 weeks within 15km radius of St Finbarr's Hospital. Referral:
  1. Patients needs to be assessed by a geriatrician prior to referral
  2. Complete outreach referral form and phone call to confirm.
0871800953
corksouth.icpop@hse.ie
North Cork Community Rehabilitation Team (CNRT) CNRT provides home rehabilitation for patients, within a 16km radius. The team consists of PT, OT, and SALT.

Inclusion

  1. Assessment completed by a PT /OT prior to referral
  2. Inpatients in acute hospitals that would benefit from rehabilitation on discharge
  3. Patients living in North Cork within 24km radius of Mallow

Referral

  1. Contact team to accept and send the referral form
 022-30790
COPD Outreach Patient must have confirmed diagnosis of COPD, and have been reviewed by respiratory consultant / registrar during their hospital admission
  1. Will receive support inclusive of home visits, for up to 2 weeks post-discharge
Referral:
  1. Patient needs to be referred to COPD Outreach team prior to discharge.
Maeve O'Grady - Clinical Specialist Physiotherapist - 0864182004
Respiratory CNS (post currently unfilled) - 0864182227

Service Description Contact Details
Reablement Provides personalised, therapy-led home support. Reablement seeks to empower clients to regain their functional and social independence after a period of deconditioning, or illness. The service lasts for 4-6 weeks, with 80% maintaining or negating their need for home support.
Inclusion Criteria:.
Age ≥65, with less that 5 hours Home Support Package, cognitive ability to learn new activities.
Exclusion Criteria:
Requires assistance of 2, existing home support package of greater than 5 hours, or advanced stages of dementia. To refer complete referral form and make contact with Reablement assessor		 All patients with level 3 & 4 priority for home support should be referred to Reablement (subject to availability in the client's area).
Key contact details:
CHN 1: Reablement OT Assessor
(Listowel / Castleisland / North Kerry)
Brid.halpin@hse.ie087 979 0131
CHN 8: Reablement OT Assessor
*Currently paused*
CHN 13: Reablement OT Assessor
(Brandon / Kinsale / Carrigaline)

Anne.ohea2@hse.ie 087 188 1772
Project Lead Fiona.geary2@hse.ie 087283 8699

Transitional Care Beds For older adults (>65) patients who require a short period of care before returning home (less than 30 days). For example patients awaiting home support packages or housing adaptions. To refer complete single referral form located on staff directory and email LCST.Cork@hse.ie
Riverstick transitional Care Beds
  1. TCB beds under the governance of CUH
  2. Supported by CUH consultant and d/c co-ordinator
  3. Access to physiotherapy and
occupational therapy		 key contact details: send online referral via ICM to discharge co-ordinators (drop down Riverstick)
Bed Management CUH Assist with patient flow, diagnostic dependent discharges, and infection control. Key contact details: Telephone: 0867872130 or 086 7872129

Service Description Contact Details
CUH Discharge Co- ordinators For patients who require input from a discharge co-ordinator to facilitate discharge including home help or long- term care, complex discharges Pauline O'Keefe – 0867872131
Eilish Madden – 0873519819
Kate Howard – 0871444459
Edel O' Leary – 0876176830
Clíona Sexton - 0870954618
Cardiology Services CUH Timely access to critical cardiology services and discharge dependent diagnostics such e.g. ECHO Cardiology Co-ordinator: 0867872299
GP diagnostics GP services have access to:
  1. Community x-ray, CT, MRI and DEXA scans for adults over the age of 16
  2. Ultrasonography services for patients over 16 with medical cards/ GP cards
  3. Urgent diagnostics within 1 month, non-urgent within 3 months
 Use website below for full list of available diagnostics
https://www.hse.ie/eng/services/list/2Primarycare/community-healthcare- networks/gp-diagnostics
MRI CUH To book an MRI to facilitate discharge please contact bed management. MRI can be organised within 1 week as outpatient 0867872130
0867872129
cuh.mri@hse.ie
Community Work Community Workers' seek to support community and voluntary services to promote health and social gain. They work with 'Meals-on-Wheels' groups, active retired, day-care centres, social centres, befriending groups, home visitation, home cleaning services, community laundries, carer support groups, LGBT+ social inclusion, peer support, health focus groups, migrant communities, Traveller and Roma groups, community initiatives and interagency work Cork South: 021 49 23120
Cork North: 021 49 28370
Kerry: 066 71 95635

Service Description Contact Details
ALONE National organisation that enables older people to live at home by providing services to support older adults including:
  1. Support and 'befriending service'
  2. Support through the provision of technology
 Online referral: www.alone.ie
Age Action Voluntary service – assist with moving bed downstairs, clear clutter, install equipment , (will not provide the equipment), small DIY jobs Key contact details: 021 2067399.
Social Prescribers Supports the health and well-being of patients by helping to link them with local supports services and activity- based programmes (e.g. exercise programmes and social clubs) Online referral: https://thewellbeingnetwork.ie/community-referral/
HSE Area Finder Upon insertion of a patients eircode or address, the map will signpost the user to the correct:
  1. Community Healthcare Network (CHN)
  2. Public Health Nursing Contact

(PHN)

  1. Older Person Community Specialist Team (ICPOP)
  2. Chronic Disease Community Specialist Team (ICPCD)
 https://hseareafinder.ie/

Content by Dr ÍOS from CUH Acute and Community Services 2023. Last edit Dr ÍOS 15/12/24.