The Hospital has recently introduced an Integrated Care Pathway in the acute cluster which will be reviewed and extended to the rest of the service following the review
A primary nurse will be allocated to each patient on admission.
A key worker from one of the other disciplines will also be identified.
The key worker and primary nurse meet regularly with each patient and develop treatment goals and an individual care plan. Risk assessment and risk management is central to the delivery of care and a risk management plan will be incorporated into each individual’s care plan. A meeting of the multidisciplinary team is held each week to monitor progress.
In the experience of the Carers Group, the allocation of responsibilities between primary nurses, key workers and the MDT is often not clear.
Case conferences are held on a regular basis to review individual patient’s treatment and care. Relatives will be invited to attend the case conference with the patient’s permission. Patients are encouraged to invite an advocate to their case conference if they wish. Other people involved in the individuals care, treatment and discharge planning may also be invited to attend the case conference.
Case conferences are the best opportunities for carers to participate in the rehabilitation of their loved ones. We urge carers to attend if possible.