Adult local servicesThe Adult Local Services programme (ALS) is about improving local services for people over 16 in Lambeth and Southwark.
Programme staff work with our clinical teams in the community and in our hospitals to join up (integrate) your care and deliver health services closer to home.
What’s changing?
You will be able to expect a better, more integrated level of care. Our programme is designed to avoid you being in hospital longer than is necessary, sometimes this will mean you receive care at home rather than being admitted. This means that some patients who might have stayed in a hospital or a specialist unit for many weeks are now getting care at home.
Our plan of improvement will run for several years. Until March 2018 we will focus on the following patient pathways:
- Long term conditions (including diabetes, heart failure, respiratory and renal conditions)
- heart failure
- neuro-rehabilitation in community settings
- extending the @home service
- improving access to urgent response and short term rehab and reablement in Southwark
- improving reablement services in Lambeth.
For example, a patient who would stay at a specialist unit as a result of a brain injury might now get intensive therapy at the Pulross Centre or at home with our enhanced neuro rehabilitation team (NETT) with the support of therapists, psychologist and support workers.
We are currently providing nursing care or monitoring for people with complex health needs at home with the @home service. We will be expanding this service to provide care to more Lambeth and Southwark people. This service includes Pal@home which provides rapid response 'out of core hours’ urgent nursing care for patients who are approaching End of Life (EoL) or have other palliative care needs.
As a result of our work so far, specialist staff such as consultant geriatricians (care of the elderly), neuro rehabilitation therapists and psychologists (NETT team), tissue viability nurses (complex ulcers) and continence nurses (bowel and bladder problems) now work regularly in the community, coming out to see you rather than you coming into hospital to see them.
Who do we work with?
The ALS programme works with our teams in the community and at our hospitals to ensure that all staff are thinking about the care needed in hospital as well as arrangements for when you return home.
When putting together a care plan for you we are talking to your GP and social care. If needed we will liaise with mental health services and pharmacists and provide equipment to ensure a ‘hospital standard service’ that is built around your needs.
We are also working with charities and other organisations such as Southwark Safe and Independent Living (SAIL), Age UK and the British Red Cross to help support you at home.
If you would like more information please email Kemi Lawal at kemi.lawal@gstt.nhs.uk.