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2012
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Developed by Community Resource Service
August 2012

THE CIIS Team aims to bridge the gap between hospital and home by providing a community based service to prevent unnecessary hospital admission/re-admission or to facilitate safe early discharge from hospital. It provides a nursing and or therapy intervention that promotes faster recovery from illness with a strong preventative emphasis in maximising independent living.
The service is made up of a Intermediate Care Consultant, Nurse Practitioners,
Nurses and HCSW’s, Physiotherapists, Occupational Therapists, Technicians and
Social Service staff.
The service accepts patients 18 years and over, operates a single point of contact and response to referrals can be within 4 hours if required.
The service offers
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Rapid health and social care assessment, intervention and short term support. Support can involve immediate homecare support and or nursing, therapy support depending on the outcome of the assessment and the needs of the patient.

Rapid therapy intervention and provision of aids as required to remain at home

Rapid medical /nursing intervention, investigations and treatment
The CIIS Nursing Team are able to provide the following interventions:

Investigate and monitor patients conditions by undertaking
GP’s, District Nurses,
Hospitals, Social
Workers, Ambulance
Service
Referrals are accepted by telephone.
Tel: 07815578356
8.30am – 5pm
(7 day working, including BH)
Named Contacts:
Annette Davies Clinical Lead
Yvonne Carter Nurse
Practitioner
Louise Thomas Nurse
Practitioner
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ECG, bladder scanning, oxygen sats monitoring, request Chest X Rays and scans and venepuncture. The Nurse Practitioners are able to review the blood results and make changes to patient’s medication accordingly.

Provide support and intervention for newly diagnosed AF for improving rate control, support for chest infections, assess, treat and support frail elderly, assess patients who have fallen, have worsening mobility or are “off their feet”
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Provide Home Intravenous Antibiotic Therapy for conditions such as cellulites, UTI and chest infections. The CIIS Nurse Practitioners are able to prescribe the relevant antibiotic, can liaise with the Consultant
Microbiologists, cannulate and administer the intravenous antibiotic on the same day as the referral.
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Provide a service to Group and Cross Match patients who require blood transfusions (who are not known to Haematology Service) who are not symptomatic to require an acute admission. CIIS Nurse Practitioners arrange for the patient to have a blood transfusion the following day at the
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Elderly Day Unit (EDU) at NPTH.
Provides a DVT Pathway for non ambulatory patients with suspected or confirmed DVT’s.
Suspected DVT – GP provides the Wells Score. CIIS Nursing Team administers anticoagulant injection takes blood for d-dimer and depending on the result arranges a Doppler Ultra Sound Scan via NPTH LAC.
Confirmed DVT – CIIS coordinates the District Nurses to take blood for INR and administer anticoagulant injection, CIIS Nurse Practitioners reviews INR daily and doses patient for oral anticoagulant therapy until the patient is therapeutic (above 2.0 on two consecutive days). The patient is then referred to INR Clinic for future management.
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Provides interventions and support in Nursing Homes for the frail elderly
GP’s, District Nurses,
Hospitals, Social
Workers, Ambulance
Service
Location of Service:
Community Integrated
Intermediate Care Service,
Cimla Hospital
Cimla
Neath
SA11 3SU
Phone: 01639 862806
Fax: 01639 862768
Email: NPTCIIS@wales.nhs.uk
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including intravenous fluids/subcutaneous fluids.
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Able to provide treatment for elevated INR levels and elevated potassium levels.
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Domiciliary sessions by the Intermediate Care Consultant are provided on a weekly basis to assess complex patients who are unable to attend Rapid
Access Clinics due to increased frailty. The Intermediate Care Consultant is a constant daily support for the CIIS Nursing Team.
Based at Neath Port Talbot Hospital, this service includes Doctors, Physiotherapists,
Occupational Therapists, Nursing Staff, Dietician, SALT and has access to Specialist
Nurses including TVN, Oxygen Assessment, Heart Failure, Diabetes and COPD. The service provides interventions that prevent hospital admission and can offer support following hospital discharge. The service accepts referrals for patients 18 years and over.
The unit provides the following interventions
 a comprehensive geriatric assessment for the frail older person preventing further health deterioration and improved quality of life.
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Falls Prevention service
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Rapid Access Clinics for admission avoidance. This involves crisis intervention and sub acute assessment for patients at high risk of rapid deterioration in health requiring specialised medical and health services.
These Clinics are provided Monday to Friday.
GP’s, District Nurses,
Hospitals
The service offers flexibility with regards scheduling the patients for attendance.
Referrals are accepted by telephone or faxed referral form
Tel: 01639 862603
Fax: 01639 862606
9am – 4pm
Monday to Friday
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Rapid access to specialist equipment and investigations including X rays,
Scans and medical intervention.
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Haematology Service which includes blood, platelet, iron transfusion and therapeutic venesection.
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Intravenous therapies including biophosphonate infusions.
The unit is unable to accommodate patients who are non weight bearing, have dementia with significant behavioural problems and where the exacerbation of the medical problem would be more appropriately managed in a specialist clinic.
Named Contacts:
Dr Firdaus Adenwalla
Sister Lynne Hall
Location of Service:
Elderly Day Unit
Neath Port Talbot Hospital
Baglan Way
Port Talbot
SA12 7BX
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Community Integrated Intermediate
Care Service
Cimla Hospital, Cimla, Neath, SA11 3SU
Tel: 01639 862806 Monday to Friday 8:30am – 5pm Mobile: 07815
578356
Fax: 01639 862768
Tel: 01639 862000 Monday - Friday 5pm – 10pm & Weekends & Bank Holidays 8:30am -
10pm
SERVICE REQUIRED: (please tick the most appropriate box, if unsure please ring to speak to a member of staff)
[ ] Rapid health and social care intervention to prevent an avoidable acute hospital admission.
[ ] To prevent or stop a progressive deterioration in a person’s physical condition or level of independence
[ ] To improve independence following hospital discharge
[ ] To reduce dependency on a social care package
[ ] To prevent premature admission into a long term care home setting
Does the referral require an urgent (within 4 hours) response: (please tick)
REFERRAL DETAILS:
[ ] Yes [ ] No
Contact details: ______________________ Date of referral: _________________
____
Name of referrer:
Designation: Signature:
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CLIENT DETAILS: This referral cannot be accepted without the consent of the client
Title: Mr / Mrs / Miss / Other
___________
Address: _________________________
Surname:
First Name:
Date of Birth: Age:
Relationship:
__________________________________________
Telephone No:
Telephone number:
Post Code:
Marital Status: Married / Single / Widowed / Divorced Access:
Does the client live alone: Yes / No. If no with whom (e.g. family, carer, etc) __________________
CLIENT CURRENT LOCATION: (please tick)
Ward: [ ] Community [ ] Hospital (please state) _________
______________________
[ ] Care Home Date of admission:
Expected date of discharge:
_____________________________
NEXT OF KIN/MAIN CONTACT:
Name:
_________________________________
CLIENTS GP: GP aware of referral: Yes/No
Name: _
Practice:
Tel No:
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_________________________________________
BRIEF SUMMARY OF EVENTS LEADING TO REFERRAL: (incl. present medical condition and reasons for hospital admission).
Please attach unified assessment, relevant therapy assessments, clinical summary or encounter report if appropriate
________________________________________________________________________________________
_
_________________________________________________________________________________________
_________________________________________________________________________________________
IF CIIS WAS NOT AVAILABLE, PLEASE TICK YOUR COURSE OF ACTION:
[ ] Admit to hospital [ ] Homecare Package [ ] Stay in hospital
[ ] Urgent Day Hospital [ ] Urgent Outpatient Appointment [ ] Other (please state)
[ ] Community Physiotherapist [ ] Residential Care
[ ] Community Occupational Therapist [ ] Nursing Home
FOR OFFICE USE ONLY:
Date and time referral received:
Received by:
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