The Adult Local Services programme (ALS) is about improving local services for people over 16 in Lambeth and Southwark.
By joining up care, our programme is supporting patients to stay at home within their local community. This means that our patients receive care at home rather than being admitted to hospital or can go home more quickly after an admission.
Some patients who might have stayed in a hospital or been referred to a specialist unit for many weeks now receive care at home.
Our plans for improving local services will run to March 2019. We are focusing on the following services and pathways:
- Services for people with multiple long-term conditions (including diabetes, heart failure, respiratory and renal conditions and mental health conditions) to help them manage their care in the best possible way
- Nursing care for patients in the community particularly the housebound
- Care for people in residential and care homes
- Care for the homeless and vulnerable adults
- Neuro-rehabilitation in community settings
- Intensive nursing care at home to prevent patients, where possible, being admitted to hospital
- Care for patients in Southwark and Lambeth who need intensive support and rehabilitation at home
- Developing clinical and community networks in local neighbourhoods to better support patients
What does this mean for our patients?
Here are some examples of how joined up care is making a difference to the lives of our patients.
A patient who would ordinarily be referred to a specialist unit because of a brain injury, for example, might now get intensive therapy at the Pulross Centre or at home. The patient will be supported by our enhanced neuro-rehabilitation team (NETT), therapists, a psychologist and support workers.
The @home service provides intensive clinical care at home, much like a hospital ward. The team keep people out of hospital or help them to return home sooner. This service includes our night-time service, Pal@home, which provides urgent nursing care to patients nearing the end of their lives who or have other palliative care needs.
As a result of our work so far, more specialist staff, such as consultant geriatricians (who care for older people), neuro-rehabilitation therapists and psychologists (NETT team), tissue viability nurses (who care for people with complex wounds) and others 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 community and hospital teams and partners from other organisations to ensure that everyone who is looking after our patients is thinking about all of their care needs.
Our staff support patients in hospital and when they return home, ensuring that they receive seamless care.
Importantly, we are working with charities and other organisations such as Southwark Safe and Independent Living (SAIL), Age UK and the British Red Cross to support our patients at home.
If you would like more information please email Kemi Lawal at firstname.lastname@example.org.
Southwark Safe and Independent Living (SAIL)
British Red Cross
NHS Choices - Live well
Adult Local Services report
Find out why 2016-2017 was an important year (PDF 840Kb).
How are we doing?
See below some of our key successes and how we supported our patients in 2016-17.
3% reduction in emergency hospital admissions for elderly people
135 patients per month supported by
25% more patients cared for at home
5% fewer visits to A&E due to a fall
7 new transfer of care navigators – helping patients home from hospital
6 new Buurtzorg neighbourhood nurses – supporting patients to look after themselves at home
1 new Southwark health and social
care team – bringing together community
rehabilitation staff and social workers
86% of patients improved their mobility due to our strength and balance classes
6 new community beds for neuro-rehabilitation patients
4,000 bed days saved
Read more in our adult local service 2016-17 report (PDF 840Kb).