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On-going interventions with vulnerable people or with complex needs

Summary :: Our programmes and services :: On-going interventions with vulnerable people or with complex needs

The Children's Social care service acts to safeguard the welfare of children from physical, emotional and sexual abuse as well as neglect. In Medway there are 134 in-house foster carers who offer placements for a total of 320 children and young people plus one in-house residential unit offering eight beds. External residential units and independent fostering agencies are also used. The Medway Family Nurse Partnership was initiated in 2010 to offer first time parents under the age of 20 a specially trained family nurse who provides one to one intensive support from early pregnancy and throughout the first two years of the child's life. The service is provided by Medway Community Healthcare and supported by partner agencies. Medway Youth Offending team provides intensive supervision and surveillance programmes for persistent young offenders. It also operates plans for preparing young people to return into the community from custody and reduce risk of re-offending.

According to a NICE (National Institute of Clinical Excellence) recommendation from 2006, bariatric surgery is offered to people with a very high BMI (body mass index) of 40 or more and those with a BMI of 35–40 who have a significant other disease such as diabetes or hypertension. Surgery is only considered once all non-surgical approaches have proven unsuccessful. Each patient is assessed on an individual basis by the specialist commissioning panel.

The GUM clinic at Medway Hospital offers two clinics per week for patients who are HIV positive or diagnosed with AIDS and follows the national guidelines provided by the British HIV Association. Social care and psychological support is provided by Medway Council based within the hospital.

The management of patients with long-term conditions is generally performed in primary care. The Quality and Outcomes framework rewards general practices for comprehensive monitoring of patients with multiple indicators across 20 clinical areas. Some patients with more complex needs are managed by a Consultant led team in Medway Foundation Trust. For example in April 2010, the Kent Cardiovascular Network led the implementation of a primary angioplasty service (pPCI) to treat patients who have suffered an ST-elevated Myocardial infarction (STEMI). Medway Community Healthcare provides specialist nurse support such as the Community Respiratory team for COPD patients. Part of their role is to carry out all home oxygen assessments ensuring the drug is dispensed and used appropriately. Often, these same patients also receive community care from social services in the form of day care, home care and residential care. The service is available to people who are elderly and frail or have a physical disability, a learning disability, a mental health problem, a drug/alcohol problem, HIV/Aids or who are registered blind and/or deaf. The aim is to enable people to retain as much of their independence as possible.

In terms of end of life care, General Practitioners provide generalist support in line with the Gold Standards Framework. Medway on Call Care (MedOCC) manage the End of Life Register known as “My Wishes” which allows patients to record electronically (via their health care worker) their wishes and advance care plans as well as their experience of the health service. Community nursing/Care Management provides care and arranges funded care packages such as help at home to meet personal care needs. The Community Palliative care Team within the Wisdom provides assessment, symptom management, advice and support for patients with complex life-limiting illness (cancer and non-cancer), as well as their family and carers. The team also provides support to the primary healthcare team. The Wisdom Hospice has a 15 bedded unit for in-patient care for symptom management and end of life care for patients referred by the specialist palliative care team. Cruse Bereavement care was commissioned in February 2012 to provide comprehensive bereavement support to Medway residents.