Recovery at home

The Recovery at Home teams operate across the whole of the South Tyneside and Sunderland region with a team based in each of the localities of South Tyneside and Sunderland.

They provide a 24 hours a day seven days a week service and are ready to respond quickly to provide support during times of illness or if someone experiences an unexpected change in their condition that could develop into a crisis. The teams respond to patients in their own homes as well as Residential and Nursing Homes.

The teams provide Urgent community response, Hospital at Home, Discharge to assess pathways as well as planned and unplanned community District nursing visits.

The team consists of experienced Nursing and Therapy Practitioners, Staff Nurses, Health Care Support workers, Therapy Assistant Practitioners, admin staff and call handlers.

We aim to support adults (from the age of 18years) across the region, who are registered with South Tyneside or Sunderland GP and need short term health and/or social care support that can help to keep them living at home. Support is tailored to a person’s needs and can be any combination of a short term care package, from nursing and/or therapy staff to get them back on their feet without having to be hospitalised or needing long term care. GP support is also available within the service (Sunderland only).

Both teams operate a single point of access for referrals and referrals are accepted from all healthcare professionals including GP’s, Ambulance service, Secondary care, Patients, family members/carers, care home support staff and social workers. Triage will be completed at the point of contact to identify the needs of the patient and the response time required for the team to respond. The Team can respond quickly to calls in order to assess patient’s needs, provide treatment and when necessary arrange services to support at home in order to reduce unnecessary visits & admissions to hospital. Response times can range from up to 2 hours, 4 hours and same day response depending on the nature of the call.

The teams provides a Hospital at Home service to support patients to leave hospital earlier by continuing their treatment at home, this can include IV medications, nebulised treatments. The teams have Advanced Clinical Practitioners that will liaise with Hospital medical staff to support the ongoing care until treatment and care is completed. The patients will then have appropriate follow up care bundles initiated to support safe discharge from the service.

The therapy staff within the team provide rapid assessment at home, following discharge from hospital, or to prevent hospital admission. Ongoing short term therapy service can also be provided to promote independence and to support patients to remain in their own homes.