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:
Referrals:The "Single Referral Form" for LCST should be completed (located in the staff directory under referral forms "Integrated Discharge Referral Form 2023") |
Key contact details: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. (See page 7)Referrals:The "Single Referral Form" for PHN should be completed (located in the staff directory under referral forms "Integrated Discharge Referral Form 2023") |
Key Contact details:Kerry: North Cork North Cork City West Cork City South Cork City |
| 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. |
Key contact details: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 (See page 7). |
Key contact details:Kerry North Cork North Cork City West Cork City South Cork City |
| Community Intervention Team (CIT) | Inclusion criteria:16km radius of Cork City, Mallow and Middleton
Exclusion criteria
|
Key contact details:Cork: Kerry: |
| 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:
|
Key contact details: Telephone: 0871800953 |
| 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
15 mile radius of Mallow.
Referral
|
Key contact details: Telephone: 022-30790 |
|
COPD Outreach |
Patient must have confirmed diagnosis of COPD, and have been reviewed by respiratory consultant / registrar during their hospital admission
|
Key contact details: 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 |
|---|---|---|
| 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 |
|
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 |
|---|---|---|
Cork University Hospital 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 |
Key contact details: |
Cardiology Services CUH |
Timely access to critical cardiology services and discharge dependent diagnostics such e.g. ECHO |
Key contact details: Telephone: |
GP diagnostics |
GP services have access to:
|
Use website below for full list of available diagnostics |
MRI CUH |
To book an MRI to facilitate discharge please contact bed management MRI can be organised within 1 week as |
Key contact details: Telephone |
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, |
Key contact details: Telephone: |
| Service | Description | Contact Details |
| ALONE | National organisation that enables older people to live at home by providing services to support older adults including:
|
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:
(PHN)
|
https://hseareafinder.ie/ |