This article explores the development of an ambulatory community service that demonstrates multidisciplinary working to meet the diverse needs of frail older people and their carers. The service comprises advanced nurse practitioners, a pharmacist, a community navigator, consultants, occupational therapists, physiotherapists, a nurse, rehabilitation assistants, a healthcare assistant and an administrator. This multidisciplinary team (MDT) serves adults with complex medical and rehabilitation needs who are being discharged from hospital, staying in bedded rehabilitation units or living at home by offering assessments, investigations and rehabilitation, where appropriate closer to home.
The aims of the service are to: keep people well, prevent unplanned hospital admissions, promote health and well-being, reduce the risk of falls, enable independent living and provide rehabilitation. Personalised care plans are developed with patients and their carers. Advanced nursing practice is demonstrated in assessment, investigation, diagnosis, management, referral and non-medical prescribing.
Development of this MDT is required to support and promote integrated, evidence-based work. Such development leads to integrated care across communities, and bridges gaps between patients and carers, GPs, home, residential and hospital-based services, and the voluntary, statutory and non-statutory sectors.
Nursing Older People. doi: 10.7748/nop.2018.e1064Citation
Featherstone A (2018) Developing a holistic, multidisciplinary community service for frail older people. Nursing Older People. doi: 10.7748/nop.2018.e1064Peer review
This article has been subject to external double-blind peer review and has been checked for plagiarism using automated softwareCorrespondence
The author would like to thank the holistic assessment rapid investigation (HARI) team for demonstrating integration of the multidisciplinary team in practice and delivering a high-quality service to patients and referrers. She would also like to thank HARI advanced pharmacist Rania Hallaq for her work in the service evaluation, and transformation lead Sue Danks and clinical operations manager Sue Brooker for their consistent encouragement
Published online: 25 October 2018
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