25 November 2020

At the height of the first Covid-19 wave in Milton Keynes a temporary Extended Hub was set up to triage patients into the care system or refer on to other services.

The Milton Keynes Integrated Community Support Team (ICST) service provided support through an extended hub for those most vulnerable to Covid-19, particularly for those whose own services had been paused.

Between April 2020 to the end of August 2020 the Hub supported more than 2,000 patients using telephone and video calls.

The team, who included physiotherapists, health care assistants and psychologists as well as nurses, linked with many local voluntary agencies that supported patients during the pandemic with food deliveries, medications deliveries, befriending services for isolated patients, as well as linking with the GP teams for patients that were medically unwell.

If a patient required a home visit, or if a risk highlighted that a patient needed a face to face visit, the Hub contacted other community services that were performing home visits to organise support.

The Hub also supported many patients with welfare checks for social isolation and shielding patients and signposted many patients onto voluntary agencies across MK.

Its presence provided peace of mind for clinicians who could refer patients on to the Hub for follow up calls and continued assessment on the telephone once the initial need had been addressed leaving more time for those patients needing more urgent care and treatment

ICSTs operate as part of the Primary Care Networks. The teams work closely with GPs to support people to manage their wider health, psychological and social needs that impact on their health and wellbeing.

The team visit on an outreach basis in community settings to assist, coach and empower patients in their unique everyday environments to find personalised ways of overcoming barriers to wellbeing.

For example, in one case, the Hub supported the partner of a patient with a terminal diagnosis.  Whilst working remotely, the hub made certain that the patient’s partner was supported, reassured and confident that the team could coordinate the right services to be involved. The team supported the partner to ensure that the patient was comfortable and symptom free during the last few weeks of life.

Leticia Sainty, Clinical Nurse Specialist for the ICST said: “The skills of communication were exceptional and although the team members were communicating via telephone the partner felt supported and gave them the confidence to telephone into the team when guidance was needed.

“The team knows that the service that they were providing was vital to provide quality of life not only to the patient but to the partner.

“The Extended Hub offering the remote service during the Covid gave the partner time to talk, reliability that the hub was there and gave them the opportunity to discuss any concerns to help reduce their anxieties and provide them comfort.” 

Another case involved a patient who was feeling anxious about reintroducing themselves back into society following the peak of the pandemic. The patient felt isolated and very alone and was referred into the extended hub.

The Extended Hub was able to use motivating skills and goal setting with the patient to work through their anxieties using video consultation. The patient also used a self-motivating app suggested by the Hub.

The patient told the Hub that if they hadn’t been there, they may well have deteriorated deeper into depression. The patient feared that their  health and mental health would have suffered far worse. The patient recognised how valuable the support from the Hub was at that time.

Now this former patient wants to help others that may also be having a difficult time with adjusting back out in society.

Speaking of the value of the Hub, Leticia said: “The team on our daily calls showed adaptability, commitment, consistency, passion as well as Trust values every member of staff in the hub was working remotely and yet we all felt like we were all together and one big team. We felt we really made a difference.”